MyHealthTeam

Member Information

Your information is protected. UPREHS will not release your information to your employer. This information is only being collected to determine your eligibility for the MyHealthTeam program. You must be a non-Medicare UPREHS member to enroll in this program.
Member Gender *
Member Name *

First Name Last Name
Best Contact Number *

Area Code Phone Number
Member Birth Date *

Month Day Year
Height *
Weight *
Member E-Mail *
Medical History
Have you ever had (Please check all that apply)

Asthma Arthritis Cancer Diabetes Fainting Spells Heart Disease Heart Attack High Blood Pressure Digestive Problems Kidney Disease Liver Disease Sleep Apnea Use a C-PAP machine Neurological Disorders Bleeding Disorders Lung Disease Emphysema Bariatric surgery
Other illnesses:
Healthy & Unhealthy Habits
Exercise

Never 1-2 days 3-4 days 5+ days
Eating Habits

My diet could use some help I watch what I eat I never diet
Alcohol Consumption

I don't drink 1-2 glasses/day 3-4 glasses/day 5+ glasses/day
Caffeine Consumption

I don't use caffeine 1-2 cups/day 3-4 cups/day 5+ cups/day
Do you use tobacco products or vape?

No Yes
Include other comments regarding your Medical History
Should be Empty:

Member Information