* 1. Please choose one of the following:

* 2. First Name:

* 3. Last Name:

* 4. Medicaid ID #:

* 5. Date of Birth

Date / Time

* 6. Gender/Sex:

* 7. Current Height (Required)

* 8. Current Weight (Required)

* 9. Phone Number (Required)

* 10. Email Address:

* 11. If we can't reach you, is there an alternate person we can contact to get your updated contact information? Please list their contact information:

* 12. In the past six (6) months, were you treated at an Emergency Department/Emergency Room or admitted to the hospital or other facility? [If more than once write down each time/event] (Required)

* 13. If yes, how many times?

* 14. Why were you treated at an Emergency Room or admitted to the hospital or other facility?

* 15. In general, how would you describe your health? (Required)

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