Health Insurance Family-Insurance-SDOH-1Download Name:(Required) First Initial Last Name Age:(Required)15-under16-1718-2425-4950-6465+Decline to RespondRace:(Required)American Indian/Alaska NativeAsianBlack or African AmericanNative Hawaiian or other Pacific IslanderWhiteDecline to RespondEthnicity:(Required)HispanicNon-HispanicDecline to RespondPhone:(Required)Email:(Required) Zip Code:(Required)20710207122074020743207442074520746207472074820782I received the following:(Required) 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:(Required) 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:(Required) I need help with the following supports:(Required) 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:(Required)
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