HEALTH SCREENING

Date of Birth:(Required)

MM slash DD slash YYYY

Zip Code:(Required)

Gender Identity:(Required)

Has the consumer received a COVID-19 Vaccine?(Required)

How many doses did you receive?(Required)

I have a primary care physician:(Required)

The last time I was seen by a Primary Care Physican was:(Required)

I'm someone who has been directly impacted by cancer:(Required)

I know someone who has been directly impacted by cancer:(Required)

The last time I participated in blood work and screening for physical health concerns was:(Required)

When I have go to the see my doctor, I feel comfortable telling them my health concerns:(Required)