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* 1. Today's Date

Date

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* 2. First Name

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* 3. Last Name

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* 4. Date of Birth

Date

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* 5. Email

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* 6. SMS Text

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* 7. Do you have any cultural, religious and/or spiritual beliefs that are important to your family’s health and wellness?

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* 8. Do you need help filling out health forms?

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* 9. Do you need help taking your medicines?

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* 10. Do you need help answering questions during a doctor’s visit?

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* 11. In general, how would you describe your physical health?

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* 12. Please provide additional information about why you chose this rating.

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* 13. Compared to one year ago, how would you describe your physical health?

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* 14. Please provide additional information about why you chose this rating.

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* 15. How many times have you been to the emergency room in the past six months?

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* 16. How many times have you been a patient in the hospital in the past six months?

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* 17. How many times have you been a patient in the hospital in the past six months?

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* 18. In the last 12 months, how many times have you been in a nursing home and/or rehab?

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* 19. Do you have a regular or specialty doctor or healthcare provider?

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* 20. Who is the Provider (name/clinic/phone)?

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* 21. When was the last time you saw your regular doctor?

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* 22. Are you currently pregnant or the father of a pregnant woman?

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* 23. Have you given birth in the last 12 months?

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* 24. When was your last dental visit?

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* 25. Do you have any problems eating (for example, appetite, chewing or swallowing)?

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* 26. Have you been told by a doctor that you have any medical conditions?

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* 27. Do you have any other conditions not listed above?

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* 28. Do you have trouble with your vision?

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* 29. If you have diabetes, have you had a diabetic eye exam done in the last year?

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* 30. Do you have trouble with your hearing?

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* 31. Are you getting wound care from a healthcare professional or care team now?

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* 32. Have you had any of the following vaccinations as an adult?

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* 33. Have you had the following screenings/tests?

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