Dear Health Care Provider: Your patient, an employee of Cooley LLP has elected to voluntarily participate in the firm’s wellness program. As a part of your patient’s participation, there are specific criteria that must be met in order to validate the completion of the wellness activities. Please note that your patient’s employer does not receive any results associated with your examination. All information is managed by an external provider, Virgin Pulse, which has the appropriate privacy and security protocols in place in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Employees at Cooley LLP may receive substantial incentives for participating in various activities, such as those you are about to perform. If you find that the activities contained within this form are medically ill-advised or if your patient is medically unable to meet the requirements, please check the “exempt” box. Your name and signature on the form verifies your patient has completed and undertaken the procedures contained within the form. Health Care Providers Performing an Annual Wellness Exam For health care providers (physicians, nurse practitioners or physician assistants) who are performing the annual wellness exam, the following criteria must be satisfied in order to qualify for your patient’s participation: 1) Standard Head-to-Toe Health Examination, including: a. BMI or hip to waist ratio b. Height and Weight c. Blood Pressure d. Other (as appropriate) 2) Comprehensive Metabolic Panel (CMP) – Required if employee has not participated in the onsite health evaluations Health Care Providers Performing a Dental Exam For health care providers (dentists or dental hygienists) who are performing the bi-annual dental exam, the following criteria must be satisfied in order to qualify for your patient’s participation: 3) Oral Examination, including: a. Integumentary assessment (oral cavity) b. Basic or deep cleaning c. Other (as appropriate) Health Care Providers Performing a Vision Exam For health care providers (optometrists or ophthalmologists) who are performing the annual eye exam, the following criteria must be satisfied in order to qualify for your patient’s participation: 4) Standard Eye Examination, including: a. PERRLA b. Visual Acuity c. Cover Test d. Color Blindness Test e. Ocular Motility f. Stereopsis g. Slit Lamp Exam h. Glaucoma Test i. Other (as appropriate) Health Examination Form To Be Completed By Employee Employee Name: Employee ID: Today’s Date: / / Gender (Check One): Male Female Birth Date: / / Phone Number: To Be Completed Health Care Providers Performing an Annual Wellness Exam Health Care Provider Name: Address: Date of Exam: / / City, State, Zip: Tests/Examinations Performed Standard Head-to-Toe Health Examination Yes No Exempt Comprehensive Metabolic Panel (CMP) Yes No Exempt/Completed Onsite Other Examination Criteria (see page 1) Yes No Exempt Other (specify): Yes No Exempt Health Care Provider Signature: Telephone Number ( ) To Be Completed by Health Care Providers Performing a Bi-Annual Dental Exam Health Care Provider Name: Address: Date of Exam: / / City, State, Zip: Tests/Examinations Performed Oral Examination Yes No Exempt Other Examination Criteria (see page 1) Yes No Exempt Other (specify): Yes No Exempt Health Care Provider Signature: Telephone Number ( ) To Be Completed by Health Care Providers Performing an Annual Eye Exam Health Care Provider Name: Address: Date of Exam: / / City, State, Zip: Tests/Examinations Performed Standard Eye Examination Yes No Exempt Other Examination Criteria (see page 1) Yes No Exempt Other (specify): Yes No Exempt Health Care Provider Signature: Telephone Number ( ) Please scan and upload this form to your Virgin Pulse personal portal or take a photo from your mobile device and upload it through your Virgin Pulse mobile app. .