Sign up for MOCHA Programs

* Required fields

Name*:

Address:

Street:

City:

State:

Zip:

Phone*:

Email:

Age*:

Race/ethnicity:

Emergency contact name:

Emergency contact phone:

1. How did you hear about MOCHA? (Check all that apply)

Internet/website

Community Organization

MOCHA Presentation

Friend

Radio

Flyers

MOCHA Mentor (name):

2. When was the last time you had the following health check-ups?

Check-up Type	Never	More than one year	Less than one year	Less than one month
a. Blood pressure	Never	More than one year	Less than one year	Less than one month
b. Prostate exam	Never	Less than one year	Less than one year	Less than one month
c. Cholesterol	Never	Less than one year	Less than one year	Less than one month
d. Eye exam	Never	Less than one year	Less than one year	Less than one month
e. Colonoscopy	Never	Less than one year	Less than one year	Less than one month

3. What current health concerns do you have? (Check all that apply)

Weight

Physical fitness

Blood pressure

Diabetes

Stress-mental or emotional

Asthma

Alcohol or drug use

Nutrition

Relationship abuse

Cancer

Other:

4. What aspect of MOCHA interests you the most? (Check all that apply)

Personal fitness

Learning more about health

Becoming a MOCHA Mentor

Improving my community

5. Please explain how MOCHA will help you to achieve your goals of becoming a healthier man.