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Peehip Wellness Screening Form
This
Birth Date:
-
Male
Contract Holder
Female
Spouse
Daytime Phone Number:
-
-
-
Last Name:
-
First Name:
Screening not performed due to:
Pregnancy
Disability
What best describes your race/ethnicity?
White
Asian
Hispanic / Latino
Other
Black / African American
Native American /
Alaska Native
Native Hawaiian / Pacific Islander
Do you have (or have you been told you had) any of the following?
High Cholesterol
High Blood Pressure
Diabetes
Do you take any medication for any of...
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