Insurance Details First Name Last Name Address Date of Birth Email Phone Number Insurance Company Name Insurance ID Group ID Did you complete your annual primary care provider office visit? YesNo If yes, please list the date seen. Primary care provider’s name. Do you smoke? YesNo If yes, did you complete smoking cessation classes? YesNo If yes, please list the date. Where you completed the classes. Did you get your annual Flu Immunization? YesNo If yes, please list the date and where you received it. Location received. Did you get your COVID 19 Vaccine? YesNo If yes, please list the date you received your 1st Johnson and Johnson or 2nd Moderna or Pfizer shot and where you got it. Location received. Did you complete your annual lab work? YesNo If yes, please list the date and where you received it. Location received. Did you have an annual dental visit? YesNo If yes, please list the date seen. Provider’s name. Are you 65+? YesNo Did you complete your annual wellness visit? YesNo If yes, please list the date seen. Provider’s name. Did you complete a depression screening? YesNo If yes, please list the date seen. Provider’s name. Did you complete your colorectal cancer screening? YesNo If yes, please list the date seen. Provider’s name. Did you complete a breast cancer screening? YesNo If yes, please list the date seen. Location completed. Do you have hypertension? YesNo If yes, please list the medication(s) you’re taking to control it. Did you complete a fall risk screening? YesNo If yes, please list the date seen. Location completed. Is your diabetes controlled (A1c<9)? YesNo If yes, please list the date seen. Location completed. Do you have a child 24 months or younger? YesNo Did your child complete their Combo 10? YesNo If yes, please list the dates. Pediatric provider. Did you bring your child to their pediatric visits: 1, 2, 4, 9, 12, 15 18 & 24 Months - please make sure all visits have been competed before selecting yes. YesNo If yes, please list the dates. Pediatric provider. Hospital Visit(s) YesNo If you have been discharged from the hospital, did you visit your primary care provider within 30 days? (we hope you’re ok) YesNo If yes, please list the date of discharge. Date you saw your primary care provider. Provider’s name. If you have been discharged from the hospital, and have Congestive Heart Failure, Pneumonia, Acute Myocardial Infarction, and/or Diabetes, did you visit your primary care provider within 3 business days? (We hope you’re ok). YesNo If yes, please list the date of discharge. Date you saw your primary care provider. Provider’s name.