Her Heart Challenge Application

Parkview Heart Institute has made a commitment to women by focusing on their unique cardiovascular needs and risks for heart disease. Together with Parkview Physician’s Group – Cardiology, we are excited to offer a program especially for women in our community who are ready to meet the challenge of reducing their own risk of heart disease. This program is called the Her Heart Challenge.

If you participate, you will attend weekly sessions beginning in August that will include resources and information to help you find your motivation and learn about your personal risks. Our health experts will help you find ways to decrease those risks and lower the chances of developing heart disease ? which remains the number one killer of women in the United States. If participating, the Her Heart Challenge will also provide you with free lab work, opportunities for activity and access to health experts.

The selection process for the Her Heart Challenge involves an application and interview with the Her Heart Challenge Team. 

You may also download the form and return to Sarah Mohrman, PPG - Cardiology, Parkview Heart Institute, 11108 Parkview Circle Drive, PO Box 5600, Fort Wayne, IN  46895-5600. Applications can also be faxed to 260-458-5850, or scanned and e-mailed to jill.zahm@parkview.com. 

Please note that these events are intended to be in-person, however for the safety of our staff and participants, virtual courses and meetings may take place, depending on the status of the COVID pandemic. We will inform participants accordingly.   
Name  *Address  *City  *State  *Zip Code  *Email Address  *Phone Number  *Shirt Size  *Do you suffer from: High blood pressure  *
High cholesterol  *
Diabetes  *
Do you smoke?  *Are you a member of the Her Heart Support Network of Parkview Heart Institute?  *Rate your readiness to make lifestyle changes to help you reach your goals, based on a scale from 1 to 5 (1 being low, 5 being high)  *Will you be able to meet the following requirements? Will you be able to meet the following requirements?


  • Pre-challenge assessment

  • Overnight stay for the HHC retreat

  • Wednesday evening meetings

  • Check-in #1

  • Check-in #2

  • Love Your Heart Expo final celebration

  • Obtain a signed release from your medical provider

  *
How did you hear about the program?  *
In 100 words or less, what is your top health goal?  *In 200 words or less, describe why you want to participate in the Her Heart Challenge  *Do you foresee in barriers to your participation in the program?  *