Health Insurance Family-Insurance-SDOH-1Download Name:(Obligatorio) First Initial Last Name Age:(Obligatorio)15-under16-1718-2425-4950-6465+Decline to RespondRace:(Obligatorio)American Indian/Alaska NativeAsianBlack or African AmericanNative Hawaiian or other Pacific IslanderWhiteDecline to RespondEthnicity:(Obligatorio)HispanicNon-HispanicDecline to RespondPhone:(Obligatorio)Email:(Obligatorio) Zip Code:(Obligatorio)20710207122074020743207442074520746207472074820782I received the following:(Obligatorio) 1st Dose of COVID-19 Vaccine 1st & 2nd Dose of COVID-19 Vaccine 1st, 2nd, and Booster Dose of COVID-19 Vaccine Decline to Respond I need help with the following health concerns:(Obligatorio) COVID-19 education, testing, vaccination and/or boosters Diabetes Prevention Programs (DPPs) Asthma Hypertension Monkey Pox Obesity Strokes Type 2 Diabetes Other health condition (please specify) List:(Obligatorio) I need help with the following supports:(Obligatorio) Behavioral health services Childcare Community-based health support Employment Finances Food Pantry Services GED, vocational or other educational services Health insurance/coverage of health expenses Housing Support/Sssistance Legal aid Personal safety Primary care medical home Social services Substance use Utilities Support Transportation Support Other (please specify) List:(Obligatorio)
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