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Synergy Saturday Online Screening Form
Please fill out and submit your easy-fill form online.
23
Questions
START
HIPAA
Compliance
1
State
*
This field is required.
Which State or U.S. Territory did your screening occur?
Two-digit State abbreviation
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2
County
*
This field is required.
Which County did your screening occur?
Full County Name
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3
Gender
*
This field is required.
How do you identify?
Female
Male
Transgender Female
Transgender Male
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4
Population Group
*
This field is required.
We're all one race. To which population group do you identify?
African-American
American-Indian
Arabian
Asian
Caucasian
Chinese
Filipino
Japanese
Korean
LatinX-American
Pacific Islander
West Indian
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5
Age Range
*
This field is required.
What is your age range?
11 - 20
21 - 30
31 - 40
41 - 50
51 - 60
61 - 70
71 - 80
81 - 90
91 - 100
101 - 110
111 - 120
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6
Are You Taking Any Prescription Medications?
*
This field is required.
On any meds?
YES
NO
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7
What Is Your Insurance Coverage Type?
*
This field is required.
Who supplements your premium?
Employer (Group)
Non-Group (Individual)
Medicaid
Medicare
Other Public (Military)
Uninsured
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8
Pulse/Heart Rate
*
This field is required.
Enter your number or leave N/A
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9
Temp.
*
This field is required.
Enter your number or leave N/A
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10
Blood Pressure - Systolic (Top Number)
*
This field is required.
Enter your number or leave N/A
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11
Blood Pressure - Diastolic (Bottom Number)
*
This field is required.
Enter your number or leave N/A
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12
Abnormal or Normal
If your BP is higher than 140/90 mm Hg, enter "Abn" for abnormal. Otherwise, leave blank for normal.
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13
Glucose (Blood Sugar)
*
This field is required.
Enter your number or leave N/A
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14
Abnormal or Normal
If your Glucose (Blood Sugar) is higher than 100 (without eating) or higher than 140 (within 2 hours of eating), enter "Abn" for abnormal. Otherwise, leave blank for normal.
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15
Cholesterol
*
This field is required.
Enter your number or leave N/A
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16
Abnormal or Normal
If your Cholesterol is higher than 239, enter "Abn" for abnormal. Otherwise, leave blank for normal.
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17
Weight (WGT)
*
This field is required.
Measured in pounds
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18
Height (HGT) - Feet
*
This field is required.
Measured in feet. Number only.
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19
Height (HGT) - Inches
*
This field is required.
Measured in inches. Number only.
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20
BMI (Body Mass Index)
*
This field is required.
Enter your number or leave N/A
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21
Pulse Oxygen
*
This field is required.
Enter your number or leave N/A
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22
Hooray!!! You Completed Your Screening Self-Report!!! You are done.
Use the emoji slider to state how it makes you feel.
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23
Please verify that you are human
*
This field is required.
Only humans can be counted for our screening numbers. Lol.
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