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Peehip Wellness Screening Form

Peehip Wellness Screening Form

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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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