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AARP (A United HealthCare Insurance Company)
ACCESS IPA
Access Medicare
Advantage by Bridgeway Health Solutions
Advantage by Superior HealthPlan
Aetna
Aetna - PPO
Aetna American Continental Ins Co
Aetna Better Health (CA)
Aetna Better Health (FL)
AETNA BETTER HEALTH (IL)
AETNA BETTER HEALTH (KY)
AETNA BETTER HEALTH (TX)
Aetna better health of louisiana
Aetna Medicare
Aetna medicare elite (PPO)
AFLAC - Medicare Supplemental
AL MEDICARE
AL- Medicare
Alabama Medicaid
Alaska Medicaid
All Savers Life Insurance
ALLWELL
AMBETTER
American Family Insurance Group - Medicare Supplem
American Health Medicare
AMERIGROUP
Anthem BCBS Kentucky
Anthem BCBS of Missouri
Anthem BCBS of Ohio
Anthem of Indiana
Arizona Medicaid (AHCCCS)
Arkansas Medicaid
Associacion De Maestros Puerto Rico
ATRIO HEALTH PLANS-BO
Aultcare
AvMed Health Plans
BCBS all states
BCBS ANTHEM VIVITY
BCBS Federal Claims
BCBS of Arkansas
BCBS of Florida
BCBS of Illinois
BCBS of Indiana
BCBS of Kentucky
BCBS of Louisiana
BCBS of Michigan (Institutional)
BCBS of Michigan (Professional)
BCBS of Michigan (Thru Blue Exchange)
BCBS of Minnesota
BCBS of New York (Excellus)
BCBS of Oklahoma
BCBS of Oregon (Regence)
BCBS of Pennsylvania (Highmark)
BCBS of Texas
BCBS of Virginia
BCBS of West Virginia
Blue Cross Blue Shield
Blue Cross Blue Shield Alabama (Commercial)
Blue Cross Blue Shield Colorado
Blue Cross Blue Shield Florida
Blue Cross Blue Shield Iowa (Wellmark)
Blue Cross Blue Shield Nebraska
Blue Cross Blue Shield North Carolina
Blue Cross Blue Shield South Carolina
Blue Cross Blue Shield Tennessee
Blue Cross Blue Shield Texas
Blue Cross Community Options
Blue Cross of California
Blue Cross of Utah (Regence)
Blue Cross Washington (Premera)
Blue Exchange
Blue Shield of Idaho
Blue Shield of Washington (Regence)
BlueCross Medicare Advantage
BRAND NEW DAY
California Medicaid (Medi-Cal)
CalOptima
Care Improvement Plus
CarePlus Health Plan
CAREPLUS HEALTH PLANS, INC.
Cerner Health Plan
CHAMPVA/Spina Bifida/Children of Women Vietnam Vets
Cigna
CIGNA HEALTH PLAN - PENNSYLVANIA
Cigna PPO
Clover Health - CarePoint Medicare Advantage
Colorado Medicaid
Connecticut Medicaid
COVENTRY HEALTH AND LIFE INSURANCE COMPANY
Coventry Health Care Carelink (Advantra)
COVENTRY HEALTH CARE OF NEBRASKA, INC.
COVENTRY MISSOURI
COVENTRYONE
Cox Health Plan
Definity Health
Delaware Medicaid
Denver Health Medical Plan
Devoted Prime
District of Columbia Medicaid
First Choice Health-BO
First Health
First Health Life
Florida Medicaid
GA Medicare
Gateway Health Plan
Geisinger Health Plan Gold
Georgia Medicaid
Government Employees Hospital Association (GEHA)
Great American Life Assurance Company Medicare Supplement
Great American Life Insurance Company Medicare Sup
Great American Life Insurance Company Medicare Supplement
HEALTH CARE LA IPA
Health Net National
HEALTH NET OF ARIZONA, INC.
HEALTHSPRING LIFE & HEALTH INSURANCE COMPANY, INC.
HealthTeam Advantage
Highmark Senior HEALTH CO
Highmark Senior Solutions
HOP-BO
Horizon BCBS of New Jersey
Horizon New Jersey Health
Humana
Humana CareSource (KY)
Humana Gold Plus HMO
HUMANA LONG TERM CARE
Humana Medicare
Idaho Medicaid
IEHP Direct
Illinois Medicaid
Independence Blue Cross (Pennsylvania)
Indiana Medicaid
Iowa Medicaid
J860872
John Hopkins Health Plan
Johns Hopkins HealthCare LLC
Kaiser Foundation Health Plan of the Mid-Atlantic
Kaiser Permanente of Georgia
Kaiser Permanente of Northern California
Kaiser Permanente of Southern California
Kansas Medicaid
ken@kenbrown.com
Kentucky Medicaid
LA Care Health Plan
Leggett & Platt
LIBERTY MUTUAL
LOS ANGELES MEDICAL CENTER LAMC
Louisiana Medicaid
Lumico
Maine Medicaid
Maryland Medicaid
Massachusetts Medicaid
MECICARE
MED
medcare
Meddicare
MEDIACARE
MEDIACRE
MEDIARE
Medica
Medica Health Plans
Medicaid
MEDICAR
Medicare
Medicare Part B
MEDICARE A AND B
Medicare Advantage - Pennsylvania
Medicare b
Medicare health
Medicare Health Insurance
Medicare Insurance
MEDICARE P
Medicare Part
Medicare Part A
Medicare Part A and B
Medicare Part B
Medicare Plus Blue
Medicare United
Medicare United Health Care
Medicare y Mucho Mas (INMEDIATA HEALTH GRP CORP)
MEDIGOLD HEALTH PLANS
Meridian Health Plan of Illinois
Meritain Health
Michigan Medicaid
Minnesota Medicaid
Mississippi Medicaid
Missouri Medicaid
Molina Healthcare of California
Molina Healthcare of Michigan
Molina Healthcare of South Carolina
Molina Healthcare of Texas
Molina Healthcare of Washington
Montana Medicaid
Motion Picture Industries-BO
Mutual of Omaha
National Association of Letter Carriers (NALC)
Nebraska Medicaid
Nevada Medicaid
New Era Insurance Company
New Hampshire Medicaid
New Jersey Medicaid
New Mexico Medicaid
New York Medicaid
North Carolina Medicaid
North Dakota Medicaid
Ohio Medicaid
Oklahoma Employees Group Insurance Division
Oklahoma Medicaid
Oregon Medicaid
Oscar Health EDI
Pacific Source Health Plan
PacifiCare (PPO)
Pan-American Life Insurance
Paramount Health
Paramount Health Care
Passport Health Plan
Pennsylvania Health and Wellness
Pennsylvania Medicaid
PPO
PPO/PRIVATE
Priority Health
Prisma Health
Puerto Rico Medicaid (ODSI)
Rhode Island Medicaid
Santa Clara Valley Health and Hospital
self
SENTRY INSURANCE
SEOUL MEDICAL GROUP
Silver Summit Health Plan
South Carolina Medicaid
South Dakota Medicaid
State Farm Health Ins-BO
State Farm Ins
Superior HealthPlan Texas
Tennessee Medicaid (TennCare)
TexanPlus (Kelsey-Seybold)
Texas Medicaid
Texas Medicaid BO-BO
Tri Care
Tricare East
TRICARE for Life
Ucare of Minnesota
UHA
UHC
UHC DUAL COMPLETE
UMR-BO
United Health
UNITED HEALTH CARE
United Healthcare
United Healthcare Alternate
United Healthcare Community Plan of PA
United Healthcare Community Plan Tennessee
UNITED HEALTHCARE NATIONAL
UnitedHealth Care
UnitedHealth Group - Community Plan
UNITEDHEALTHCARE
UNITEDHEALTHCARE GROUP MEDICARE ADVANTAGE
UNITEDHEALTHCARE INSURANCE COMPANY -
UnitedHealthcare Plan of the River Valley
Unity Health Plans
Univera
Universal American
University of Utah Health Plans
UPMC Health Plan (Tristate)
Utah Medicaid
VA Fee Basis Program
VA Health Administration Center
Vermont Medicaid
Veteran Administrators (VA) Healthcare
VETERANS AFFAIRS FEE BASIS PROGRAM
Virginia Medicaid
Washington Medicaid
Wellcare
WellCare Health Plans
WELLCARE OF FLORIDA, INC.
WELLCARE PRESCRIPTION INSURANCE, INC.
Wellcare Texan Plus
Wellsense
West Virginia Medicaid
Wisconsin Medicaid
Insurance Type
*
PPO
HMO
Medicare Part B
Medicare
Medicaid
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*
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Add Secondary Insurance
Policy Holder
Self
Spouse/Partner
Parent/Guardian
Child
Other
First Name (if not Self)
Last Name (if not Self)
DOB (if not Self)
*
Insurance Name
AARP (A United HealthCare Insurance Company)
ACCESS IPA
Access Medicare
Advantage by Bridgeway Health Solutions
Advantage by Superior HealthPlan
Aetna
Aetna - PPO
Aetna American Continental Ins Co
Aetna Better Health (CA)
Aetna Better Health (FL)
AETNA BETTER HEALTH (IL)
AETNA BETTER HEALTH (KY)
AETNA BETTER HEALTH (TX)
Aetna better health of louisiana
Aetna Medicare
Aetna medicare elite (PPO)
AFLAC - Medicare Supplemental
AL MEDICARE
AL- Medicare
Alabama Medicaid
Alaska Medicaid
All Savers Life Insurance
ALLWELL
AMBETTER
American Family Insurance Group - Medicare Supplem
American Health Medicare
AMERIGROUP
Anthem BCBS Kentucky
Anthem BCBS of Missouri
Anthem BCBS of Ohio
Anthem of Indiana
Arizona Medicaid (AHCCCS)
Arkansas Medicaid
Associacion De Maestros Puerto Rico
ATRIO HEALTH PLANS-BO
Aultcare
AvMed Health Plans
BCBS all states
BCBS ANTHEM VIVITY
BCBS Federal Claims
BCBS of Arkansas
BCBS of Florida
BCBS of Illinois
BCBS of Indiana
BCBS of Kentucky
BCBS of Louisiana
BCBS of Michigan (Institutional)
BCBS of Michigan (Professional)
BCBS of Michigan (Thru Blue Exchange)
BCBS of Minnesota
BCBS of New York (Excellus)
BCBS of Oklahoma
BCBS of Oregon (Regence)
BCBS of Pennsylvania (Highmark)
BCBS of Texas
BCBS of Virginia
BCBS of West Virginia
Blue Cross Blue Shield
Blue Cross Blue Shield Alabama (Commercial)
Blue Cross Blue Shield Colorado
Blue Cross Blue Shield Florida
Blue Cross Blue Shield Iowa (Wellmark)
Blue Cross Blue Shield Nebraska
Blue Cross Blue Shield North Carolina
Blue Cross Blue Shield South Carolina
Blue Cross Blue Shield Tennessee
Blue Cross Blue Shield Texas
Blue Cross Community Options
Blue Cross of California
Blue Cross of Utah (Regence)
Blue Cross Washington (Premera)
Blue Exchange
Blue Shield of Idaho
Blue Shield of Washington (Regence)
BlueCross Medicare Advantage
BRAND NEW DAY
California Medicaid (Medi-Cal)
CalOptima
Care Improvement Plus
CarePlus Health Plan
CAREPLUS HEALTH PLANS, INC.
Cerner Health Plan
CHAMPVA/Spina Bifida/Children of Women Vietnam Vets
Cigna
CIGNA HEALTH PLAN - PENNSYLVANIA
Cigna PPO
Clover Health - CarePoint Medicare Advantage
Colorado Medicaid
Connecticut Medicaid
COVENTRY HEALTH AND LIFE INSURANCE COMPANY
Coventry Health Care Carelink (Advantra)
COVENTRY HEALTH CARE OF NEBRASKA, INC.
COVENTRY MISSOURI
COVENTRYONE
Cox Health Plan
Definity Health
Delaware Medicaid
Denver Health Medical Plan
Devoted Prime
District of Columbia Medicaid
First Choice Health-BO
First Health
First Health Life
Florida Medicaid
GA Medicare
Gateway Health Plan
Geisinger Health Plan Gold
Georgia Medicaid
Government Employees Hospital Association (GEHA)
Great American Life Assurance Company Medicare Supplement
Great American Life Insurance Company Medicare Sup
Great American Life Insurance Company Medicare Supplement
HEALTH CARE LA IPA
Health Net National
HEALTH NET OF ARIZONA, INC.
HEALTHSPRING LIFE & HEALTH INSURANCE COMPANY, INC.
HealthTeam Advantage
Highmark Senior HEALTH CO
Highmark Senior Solutions
HOP-BO
Horizon BCBS of New Jersey
Horizon New Jersey Health
Humana
Humana CareSource (KY)
Humana Gold Plus HMO
HUMANA LONG TERM CARE
Humana Medicare
Idaho Medicaid
IEHP Direct
Illinois Medicaid
Independence Blue Cross (Pennsylvania)
Indiana Medicaid
Iowa Medicaid
J860872
John Hopkins Health Plan
Johns Hopkins HealthCare LLC
Kaiser Foundation Health Plan of the Mid-Atlantic
Kaiser Permanente of Georgia
Kaiser Permanente of Northern California
Kaiser Permanente of Southern California
Kansas Medicaid
ken@kenbrown.com
Kentucky Medicaid
LA Care Health Plan
Leggett & Platt
LIBERTY MUTUAL
LOS ANGELES MEDICAL CENTER LAMC
Louisiana Medicaid
Lumico
Maine Medicaid
Maryland Medicaid
Massachusetts Medicaid
MECICARE
MED
medcare
Meddicare
MEDIACARE
MEDIACRE
MEDIARE
Medica
Medica Health Plans
Medicaid
MEDICAR
Medicare
Medicare Part B
MEDICARE A AND B
Medicare Advantage - Pennsylvania
Medicare b
Medicare health
Medicare Health Insurance
Medicare Insurance
MEDICARE P
Medicare Part
Medicare Part A
Medicare Part A and B
Medicare Part B
Medicare Plus Blue
Medicare United
Medicare United Health Care
Medicare y Mucho Mas (INMEDIATA HEALTH GRP CORP)
MEDIGOLD HEALTH PLANS
Meridian Health Plan of Illinois
Meritain Health
Michigan Medicaid
Minnesota Medicaid
Mississippi Medicaid
Missouri Medicaid
Molina Healthcare of California
Molina Healthcare of Michigan
Molina Healthcare of South Carolina
Molina Healthcare of Texas
Molina Healthcare of Washington
Montana Medicaid
Motion Picture Industries-BO
Mutual of Omaha
National Association of Letter Carriers (NALC)
Nebraska Medicaid
Nevada Medicaid
New Era Insurance Company
New Hampshire Medicaid
New Jersey Medicaid
New Mexico Medicaid
New York Medicaid
North Carolina Medicaid
North Dakota Medicaid
Ohio Medicaid
Oklahoma Employees Group Insurance Division
Oklahoma Medicaid
Oregon Medicaid
Oscar Health EDI
Pacific Source Health Plan
PacifiCare (PPO)
Pan-American Life Insurance
Paramount Health
Paramount Health Care
Passport Health Plan
Pennsylvania Health and Wellness
Pennsylvania Medicaid
PPO
PPO/PRIVATE
Priority Health
Prisma Health
Puerto Rico Medicaid (ODSI)
Rhode Island Medicaid
Santa Clara Valley Health and Hospital
self
SENTRY INSURANCE
SEOUL MEDICAL GROUP
Silver Summit Health Plan
South Carolina Medicaid
South Dakota Medicaid
State Farm Health Ins-BO
State Farm Ins
Superior HealthPlan Texas
Tennessee Medicaid (TennCare)
TexanPlus (Kelsey-Seybold)
Texas Medicaid
Texas Medicaid BO-BO
Tri Care
Tricare East
TRICARE for Life
Ucare of Minnesota
UHA
UHC
UHC DUAL COMPLETE
UMR-BO
United Health
UNITED HEALTH CARE
United Healthcare
United Healthcare Alternate
United Healthcare Community Plan of PA
United Healthcare Community Plan Tennessee
UNITED HEALTHCARE NATIONAL
UnitedHealth Care
UnitedHealth Group - Community Plan
UNITEDHEALTHCARE
UNITEDHEALTHCARE GROUP MEDICARE ADVANTAGE
UNITEDHEALTHCARE INSURANCE COMPANY -
UnitedHealthcare Plan of the River Valley
Unity Health Plans
Univera
Universal American
University of Utah Health Plans
UPMC Health Plan (Tristate)
Utah Medicaid
VA Fee Basis Program
VA Health Administration Center
Vermont Medicaid
Veteran Administrators (VA) Healthcare
VETERANS AFFAIRS FEE BASIS PROGRAM
Virginia Medicaid
Washington Medicaid
Wellcare
WellCare Health Plans
WELLCARE OF FLORIDA, INC.
WELLCARE PRESCRIPTION INSURANCE, INC.
Wellcare Texan Plus
Wellsense
West Virginia Medicaid
Wisconsin Medicaid
Insurance Type
PPO
HMO
Medicare Part B
Medicare
Medicaid
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Answer the following questions:
Do you take multiple medications?
No
Yes
Do you take medications for your heart, such as blood thinners, or medications for psychological conditions such as depression?
No
Yes
Do you have any heart-related conditions?
No
Yes
Do you have family members with heart-related conditions?
No
Yes
Do you have, or have you had cancer?
No
Yes
Do you have family members that have been diagnosed with cancer?
No
Yes
Do you have diabetes?
No
Yes
Do you have family members that have diabetes, obesity, or obesity related disorders?
No
Yes
Do you experience leg pain?
No
Yes
Are your legs swollen, painful, red, or warm to the touch?
No
Yes
Have you been diagnosed with Parkinson’s disease, Alzheimer’s Disease, Huntington’s Disease, or Dementia?
No
Yes
Do you have family members that have been diagnosed with Parkinson’s disease, Alzheimer’s Disease, Huntington’s Disease or Dementia?
No
Yes
Have you ever been diagnosed with congestive heart failure, chronic bronchitis, pulmonary emphysema, or COPD?
No
Yes
Are you interested in testing for Covid-19?
No
Yes
Are you interested in testing for Covid/Flu?
No
Yes
Are you interested in continuous glucose monitoring?
No
Yes
Are you interested in Peanut Allergy testing?
No
Yes
Is the individual on Omalizumab (Xolair)?
No
Yes
Is the individual on immunotherapy for foods?
No
Yes
Is the individual being treated for multiple myeloma?
No
Yes
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Confirm the test(s) you'd like to proceed with:
Hereditary Cancer Screening
Pharmacogenomics Testing
Cardiovascular Genetic Testing
Diabetes and Obesity Genetic Testing
Peripheral Artery Disease (PAD) Precheck
Chronic Venous Insufficiency (CVI) Precheck
APD
Cardiopulmonary
Covid-19
Covid/Flu
Continuous Glucose Monitoring (CGM)
Peanut Allergy
Peanut Allergy DTC
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CGX
Is there a history of cancer in your family? (Family History)
No
Yes
Unknown
Relationship
Family Side
Age at diagnosis
Cancer Site(s)
Select
Father
Mother
Brother
Sister
Son
Daughter
Half-brother
Half-sister
Grandfather
Grandmother
Grandson
Granddaughter
Aunt
Uncle
Niece
Nephew
First Cousin Male
First Cousin Female
Great-grandfather
Great-grandmother
Great-grandson
Great-granddaughter
Great-Aunt
Great-Uncle
Select
Paternal
Maternal
Both
Select
Bladder
Bone
Brain
Breast
Cervical
Colon
Colon Adenomas
Colorectal
Endocrine
Endometrial
Hematological
Intestine
Kidney
Leukemia
Liver
Lung
Lymphoma
Melanoma
Ovarian
Pancreatic
Prostate
Renal
Stomach
Throat
Thyroid
Uterine
20 or more Colon Polyps
Other
Add More
Personal Cancer History
Please answer YES/NO to the following personal history questions.
Bladder Cancer/Tumor?
No
Yes
Age at Diagnosis
Are you currently in treatment for this cancer?
No
Yes
Brain Cancer/Tumor?
No
Yes
Age at Diagnosis
Are you currently in treatment for this cancer?
No
Yes
Breast Cancer/Tumor?
No
Yes
Age at Diagnosis
Are you currently in treatment for this cancer?
No
Yes
Was the Breast Cancer/Tumor Bilateral?
No
Yes
Was the Breast Cancer/Tumor Premenopausal?
No
Yes
Was the Breast Cancer/Tumor Triple Negative?
No
Yes
Was the Breast Cancer/Tumor Multiple Primaries?
No
Yes
Cervical
No
Yes
Age at Diagnosis
Are you currently in treatment for this cancer?
No
Yes
Colon/Rectal Cancer/Tumor?
No
Yes
Age at Diagnosis
Are you currently in treatment for this cancer?
No
Yes
Have you ever had a colonoscopy?
No
Yes
When was your last colonoscopy?
1 mth ago
2 mths ago
6 mths ago
1 yr ago
Over 2 yrs ago
Did they find anything abnormal from the colonoscopy?
No
Yes
Did colonoscopy find polyps?
No
Yes
Number of polyps found?
Did they do a biopsy after colonoscopy?
No
Yes
Any other tumor(s) that where benign?
No
Yes
Endocrine Cancer? (Adrenal, Neuroendocrine, Parathyroid, Pituitary, Thyroid)
No
Yes
Age at Diagnosis
Are you currently in treatment for this cancer?
No
Yes
Endometrial
No
Yes
Age at Diagnosis
Are you currently in treatment for this cancer?
No
Yes
Esophagus
No
Yes
Age at Diagnosis
Are you currently in treatment for this cancer?
No
Yes
Fallopian Tube Cancer
No
Yes
Age at Diagnosis
Are you currently in treatment for this cancer?
No
Yes
Hematologic Cancer/Leukemia?
No
Yes
Age at Diagnosis
Are you currently in treatment for this cancer?
No
Yes
Intestine
No
Yes
Age at Diagnosis
Are you currently in treatment for this cancer?
No
Yes
Kidney Cancer/Tumor?
No
Yes
Age at Diagnosis
Are you currently in treatment for this cancer?
No
Yes
Liver Cancer/Tumor?
No
Yes
Age at Diagnosis
Are you currently in treatment for this cancer?
No
Yes
Lung Cancer?
No
Yes
Age at Diagnosis
Are you currently in treatment for this cancer?
No
Yes
Lymphoma Cancer
No
Yes
Age at Diagnosis
Are you currently in treatment for this cancer?
No
Yes
Lynch Syndrome
No
Yes
Age at Diagnosis
Are you currently in treatment for this cancer?
No
Yes
Melanoma Cancer
No
Yes
Age at Diagnosis
Are you currently in treatment for this cancer?
No
Yes
Ovarian
No
Yes
Age at Diagnosis
Are you currently in treatment for this cancer?
No
Yes
Pancreatic Cancer/Tumor?
No
Yes
Age at Diagnosis
Are you currently in treatment for this cancer?
No
Yes
Respitory organs (sinuses, nasal cavities)
No
Yes
Age at Diagnosis
Are you currently in treatment for this cancer?
No
Yes
Sarcoma Cancer
No
Yes
Age at Diagnosis
Are you currently in treatment for this cancer?
No
Yes
Small Intestine
No
Yes
Age at Diagnosis
Are you currently in treatment for this cancer?
No
Yes
Stomach Cancer/Tumor?
No
Yes
Age at Diagnosis
Are you currently in treatment for this cancer?
No
Yes
Testis
No
Yes
Age at Diagnosis
Are you currently in treatment for this cancer?
No
Yes
Trachea/Broncheus/Lung
No
Yes
Age at Diagnosis
Are you currently in treatment for this cancer?
No
Yes
Uterine
No
Yes
Age at Diagnosis
Are you currently in treatment for this cancer?
No
Yes
Other Cancer/Tumor?
No
Yes
Age at Diagnosis
Are you currently in treatment for this cancer?
No
Yes
Other Cancer/Tumor Name?
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PGX
Current medications.
Add More
Are you taking any pain medication or currently on a pain management program?
No
Yes
Unknown
Are any of the medications you are taking considered opiates?
Common examples include Codeine, Oxycodone, Hydrocodone, Tramadol, Morphone, Hydromorphone, Fentanyl and Carfentanil.
No
Yes
Unknown
Have you experienced any adverse reactions to pain medications?
An adverse reaction is an unintended effect of a medication that is harmful or unpleasant. Examples of adverse reactions include cough, nausea, vomiting, diarrhea, headaches, and skin reactions (rashes, itching).
No
Yes
Unknown
Are you on multiple prescriptions for pain management?
No
Yes
Unknown
Do you have chronic pain?
No
Yes
Unknown
Specify the type of chronic pain?
Joint Pain
Knee Pain
Low Back Pain
Pain in Limb(s)
Fibromyalgia
Myalgia
Pain from inflamation (mysitis)
Arthritis Pain
Are you on any cardiac medications?
No
Yes
Unknown
Have you experienced any cardiac chest pain?
No
Yes
Unknown
Have you experienced shortness of breath?
No
Yes
Unknown
Have you been diagnosed with High Cholesterol?
No
Yes
Unknown
Have you ever been diagnosed with hypertension?
No
Yes
Unknown
Are you taking any anti-thrombotic medications (to reduce blood clots)?
No
Yes
Unknown
Are you on any psychiatric medications?
No
Yes
Unknown
Have you ever been diagnosed with depression or depressive disorder?
No
Yes
Unknown
Have you experienced depressive episodes lasting 2 weeks or more?
No
Yes
Unknown
Have you ever been diagnosed with bipolar disorder?
No
Yes
Unknown
Have you ever been diagnosed with anxiety or anxiety disorder?
No
Yes
Unknown
Have you ever been diagnosed with heart disease?
No
Yes
Unknown
Have you been diagnosed with an abnormal heart beat?
No
Yes
Unknown
Abnormal heart beat attributes
Arrhythmia
Long QT syndrome
Ventricular Tachycordia
Unknown
Have you ever been diagnosed with a heart attack?
No
Yes
Unknown
Have you ever had a stroke?
No
Yes
Unknown
Year of stroke
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Cardiac
Have you ever had an abnormal Echocardiogram (ECG) or Electrocardiogram (EKG) reading?
No
Yes
Unknown
Year or approximate date of abnormal ECG/EKG reading
Do you have sudden cardiac arrest?
No
Yes
Unknown
Have you been diagnosed with an abnormal heart beat?
No
Yes
Unknown
Abnormal heart beat attributes
Arrhythmia
Long QT syndrome
Ventricular Tachycordia
Unknown
Have you ever been diagnosed with a heart attack?
No
Yes
Unknown
Have you ever had a stroke?
No
Yes
Unknown
Year of stroke
Do you have a pacemaker?
No
Yes
Unknown
Do you have a stent?
No
Yes
Unknown
Have you been diagnosed with AFib?
No
Yes
Unknown
What type?
Persistent
Long Standing
Unknown
Have you ever been diagnosed with heart disease?
No
Yes
Unknown
Have you ever had a heart bypass surgery?
No
Yes
Unknown
Have you ever been diagnosed with cardiomyopathy?
No
Yes
Unknown
Type of cardiomyopathy
Hypertrophic (Obstructive)
Dilated (Enlarged heart Chambers Due to Weakened Hheart)
Restrictive (Rigid Lower-chambers of the Heart)
ATTR-CM (Transthyretin Amyloid)
Other/Unknown
Have you been diagnosed or experienced any of the following conditions?
Hepatitis C
No
Yes
Age at Diagnosis
Acute bronchitis
No
Yes
Age at Diagnosis
Type 2 Diabetes
No
Yes
Age at Diagnosis
Did you experience complications from Diabetes?
No
Yes
What types of complications did you experience? (check all that apply)
Nerve Damage
Kidney Damage
Eye Damage
Hearing Imparment
Other Complications
Muscular dystrophy
No
Yes
Age at Diagnosis
Type of Muscular Dystrophy
Congenital (present at birth) myopathy (muscle disease)
No
Yes
Age at Diagnosis
Metabolic Myopathy
(A genetic disease that affects the metabolism due to lacking certain enzymes that provide energy to help muscles contract.)
No
Yes
Age at Diagnosis
Type of Myopathy
Lipodystrophy
No
Yes
Age at Diagnosis
Type of Lipodystrophy
Known Familial hypercholesterolemia genetic disorder
No
Yes
Unknown
Do you have any family history of heart-related conditions?
No
Yes
Unknown
Please list all family members that have history of heart-related conditions
Relationship
Family Side
Condition
Select
Father
Mother
Brother
Sister
Son
Daughter
Half-brother
Half-sister
Grandfather
Grandmother
Grandson
Granddaughter
Aunt
Uncle
Niece
Nephew
First Cousin Male
First Cousin Female
Great-grandfather
Great-grandmother
Great-grandson
Great-granddaughter
Great-Aunt
Great-Uncle
Select
Paternal
Maternal
Both
Select
Atherosclerosis
Cardiomyopathy
Hypertension
Heart Attack
Heart Disease
Heart Failure
High Cholesterol
Sudden Cardiac Death
Stroke
Other
Add More
Have you experienced any cardiac chest pain?
No
Yes
Unknown
Have you been diagnosed with High Cholesterol?
No
Yes
Unknown
Have you ever been diagnosed with hypertension?
No
Yes
Unknown
Current medications.
Add More
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Diabetes
Current medications.
Add More
Do you have diabetes?
Yes
No
Unknown
What type of diabetes do you have?
(Including pre-diabetes, type-1, or type-2)
Type 1
Type 2
Pre-Diabetes
Unknown
Age at Diagnosis
Did you experience complications from Diabetes?
No
Yes
Unknown
What types of complications did you experience? (check all that apply)
Nerve Damage
Kidney Damage
Eye Damage
Hearing Imparment
Other Complications
Other Complications
Have you been diagnosed with High Cholesterol?
No
Yes
Unknown
Have you experienced essential hypertension?
No
Yes
Unknown
Have you ever been diagnosed with depression or depressive disorder?
No
Yes
Unknown
Have you ever been diagnosed with anxiety or anxiety disorder?
No
Yes
Unknown
Has your weight changed over the past year?
No
Yes
Unknown
How so?
Weight Gain
Weight Loss
Do you have any family members that been diagnosed with any form of diabetes, obesity, or weight-related conditions?
No
Yes
Unknown
Please list All of the diagnoses.
Relationship
Family Side
Age at Diagnosis
Living/Decesased
Disease type
Select
Father
Mother
Brother
Sister
Son
Daughter
Half-brother
Half-sister
Grandfather
Grandmother
Grandson
Granddaughter
Aunt
Uncle
Niece
Nephew
First Cousin Male
First Cousin Female
Great-grandfather
Great-grandmother
Great-grandson
Great-granddaughter
Great-Aunt
Great-Uncle
Select
Paternal
Maternal
Both
Select
Living
Decesased
Select
Overweight
Obesity
Diabetes
Other
Add More
Are you physicially active?
No
Yes
Unknown
How many times a week do you participate in a physical activity?
Do you drink alcohol?
No
Yes
Unknown
How many alcoholic beverages do you drink per week?
Do you use tobacco?
No
Yes
Unknown
How many times do you use tobacco on an average day?
Do you eat fast food or have a high sugar diet?
No
Yes
Unknown
Do you regularly feel tired or fatigued?
No
Yes
Unknown
Do you often have excessive thirst?
No
Yes
Unknown
Have you ever been diagnosed with Neuropathy?
(Tingling in your hands or feet)
No
Yes
Unknown
Have you or a family member been diagnosed with a Leptin deficiency?
No
Yes
Unknown
Have you ever had gastric bypass surgery?
No
Yes
Unknown
When did you undergo the surgery.
Do you suffer from sleep apnea?
No
Yes
Unknown
Have you been diagnosed with a MC4R deficiency?
No
Yes
Unknown
When were you diagnosed with MC4R deficiency?
Have you ever been diagnosed with Retinopathy?
(Damage to the retina of the eyes)
No
Yes
Unknown
Do you know what your A1C is?
No
Yes
Unknown
What is your A1 C Number
Have you experienced any of the following
Eye Disease
Sexual Problems
Frequent Urination
Kidney Disease
Excessive Sweating
Teeth/Gum Problems
Asthma
Bronchitis
COPD
Frequent Headaches
Acid Reflux/GURD
Dry Mouth
Trembling
Heart Problems
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PAD
Are you 50 years or older?
No
Yes
Do you smoke or have you ever smoked?
No
Yes
Have you been diagnosed with any of the following:
PAD (Peripheral Artery Disease)
Diabetes
Chronic kidney disease
High blood pressure
High cholesterol
Cardiac disease
Stroke
Do you have a family history of PAD?
No
Yes
Family History
Relationship
Family Side
Age at diagnosis
Select
Father
Mother
Brother
Sister
Son
Daughter
Half-brother
Half-sister
Grandfather
Grandmother
Grandson
Granddaughter
Aunt
Uncle
Niece
Nephew
First Cousin Male
First Cousin Female
Great-grandfather
Great-grandmother
Great-grandson
Great-granddaughter
Great-Aunt
Great-Uncle
Select
Paternal
Maternal
Both
Add More
Do you experience tiredness, heaviness, or cramping in the leg muscles, especially during activity?
No
Yes
When you inspect your toes and feet, do they appear pale, discolored, or blue?
No
Yes
Do you experience leg pain?
No
Yes
Does it disturb your sleep?
No
Yes
Have you experienced sores or wounds on the toes, feet, or legs that heal slowly or not at all?
No
Yes
Does one leg or foot regularly feel colder than the other?
No
Yes
Have you noticed poor nail growth and decreased hair growth over time on the toes and legs?
No
Yes
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CVI
Are your legs swollen, painful, red, or warm to the touch?
No
Yes
Have you had a blood clot in a vein that caused inflammation, pain, or irritation?
No
Yes
Do you have varicose veins (veins that are enlarged or swollen and raised above the surface of the skin) in the legs?
No
Yes
Have you ever had Deep Vein Thrombosis (DVT) in the past?
No
Yes
Have you experienced pain, swelling, changes in skin color, cellulitis, or non-healing ulcers?
No
Yes
Do your legs feel heavy, tired, restless, or achy?
No
Yes
Do you have swollen feet, ankles, or legs
No
Yes
If you press on your swollen area for 10 seconds and release, do your fingers leave a dimple?
No
Yes
Does the skin look stretched or shiny?
No
Yes
Do you have ulcers on the inside of your ankle?
No
Yes
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APD
Have you been diagnosed with Parkinson’s disease, Alzheimer’s Disease, Huntington’s Disease, or Dementia?
No
Yes
Which have you been diagnosed with
Parkinson’s Disease
Alzheimer’s Disease
Huntington’s Disease
Dementia
Age of diagnosis
Do you have family members that have been diagnosed with Parkinson’s disease, Alzheimer’s Disease, Huntington’s Disease or Dementia?
No
Yes
Relationship
Family Side
Age at diagnosis
Disease Type
Select
Father
Mother
Brother
Sister
Son
Daughter
Half-brother
Half-sister
Grandfather
Grandmother
Grandson
Granddaughter
Aunt
Uncle
Niece
Nephew
First Cousin Male
First Cousin Female
Great-grandfather
Great-grandmother
Great-grandson
Great-granddaughter
Great-Aunt
Great-Uncle
Select
Paternal
Maternal
Both
Select
Parkinson’s Disease
Alzheimer’s Disease
Huntington’s Disease
Dementia
Add More
Have you ever experienced any of the following neurological symptoms? Check all that apply.
Abnormal Brain Imaging
Difficulty Moving (Motor functions)
Uncontrollable Movements
Memory Loss that interferes with daily life
Hand tremor at rest
Have you ever experienced any of the following psychiatric or memory conditions? Check all that apply.
Mood Changes or Mood Swings
Changes in Personality
Psychiatric Manifestations
Difficulty Holding Conversations
Difficulty Completing familiar and routine tasks
General Confusion of Place or Time
Have you ever experienced a seizure?
Yes
No
Unknown
Year
Have you been diagnosed with Hypertension?
Yes
No
Unknown
Have you been diagnosed with High Cholesterol?
Yes
No
Unknown
Do you have diabetes?
Yes
No
Unknown
What type of diabetes do you have?
Type 1
Type 2
Pre-Diabetes
Unknown
Do you have any known genetic abnormalities or conditions?
Yes
No
Unknown
Type
Do you have a known APOE Genotype?
Yes
No
Unknown
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Cardiopulmonary
Have you ever had a respiratory infection such as pneumonia or influenza?
Yes
No
Do you have trouble breathing? (To include wheezing, or shortness of breath)
Yes
No
Have you been diagnosed with pulmonary edema or early onset pulmonary emphysema?
Yes
No
Do you have heart disease or other heart problems?
Arrhythmia
Right-sided Heart Failure
Rapid Heartbeat
Heart Disease
Do you have swelling in the legs or belly area?
Yes
No
Do you experience fatigue?
Yes
No
Do you have any of the following breathing or lung conditions?
COPD
Bronchitis
Do you have any family history of lung or pulmonary conditions?
Yes
No
Family History
Relationship
Family Side
Age at Diagnosis
Condition
Select
Father
Mother
Brother
Sister
Son
Daughter
Half-brother
Half-sister
Grandfather
Grandmother
Grandson
Granddaughter
Aunt
Uncle
Niece
Nephew
First Cousin Male
First Cousin Female
Great-grandfather
Great-grandmother
Great-grandson
Great-granddaughter
Great-Aunt
Great-Uncle
Select
Paternal
Maternal
Both
Select
Chronic Bronchitis
Heart Failure
COPD
Pulmonary Emphysema
Add More
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Next
Covid-19
Do you currently have a fever of 100.4 or more?
No
Yes
Do you have a cough?
No
Yes
Are you experiencing shortness of breath?
No
Yes
Have you come into contact with anyone diagnosed with the coronavirus in the last 10 days?
No
Yes
Unknown
Do you have any of the following? (check all that apply)
Acute Bronchitis
Acute Pharyngitis
Acute Sinusitis
Asthma
Chronic Sinusitis
Chronic Conditions that weaken the immune system (cancer autoimmune disorders bone marrow/solid organtransplant)
Diabetes
HIV
Heart Disease
Kidney Disease/Dialysis
Liver Disease
Lung Disease
Overweight or Obese
Pneumonia
Immunodeficiency Disorder
Type of disease
Sickle Cell Disease
Are you over the age 65?
No
Yes
Are you a first responder or medical professional?
No
Yes
Have you experienced any of these symptoms in the last 10 days?
Fever or feeling feverish (such as chills sweating)
Muscle aches or body aches
Unusual Fatigue
Headache
New loss of taste or smell
Congestion or runny nose
Nausea or vomiting
Diarrhea
When did your symptoms first appear (MM/DD/YYYY)
Did the infection require hospitalizations?
No
Yes
Unknown
Do you live in a long-term care facility, nursing home, homeless shelter, or housing at an institute of higher education?
No
Yes
Have you been tested for Covid-19 in the last 10 days?
No
Yes
What were the results of your previous test?
Negative
Positive
Are you currently pregnant?
No
Yes
Is this your first test for Covid-19?
No
Yes
Unknown
Was the patient admitted to intensive care unit (ICU) for Covid-19?
No
Yes
Unknown
Previous
Next
Covid/Flu
Do you currently have a fever of 100.4 or more?
No
Yes
Do you have a cough?
No
Yes
Are you experiencing shortness of breath?
No
Yes
Have you come into contact with anyone diagnosed with the coronavirus in the last 10 days?
No
Yes
Unknown
Do you have any of the following? (check all that apply)
Acute Bronchitis
Acute Pharyngitis
Acute Sinusitis
Asthma
Chronic Sinusitis
Chronic Conditions that weaken the immune system (cancer autoimmune disorders bone marrow/solid organtransplant)
Diabetes
HIV
Heart Disease
Kidney Disease/Dialysis
Liver Disease
Lung Disease
Overweight or Obese
Pneumonia
Immunodeficiency Disorder
Type of disease
Sickle Cell Disease
Are you over the age 65?
No
Yes
Are you a first responder or medical professional?
No
Yes
Have you experienced any of these symptoms in the last 10 days?
Fever or feeling feverish (such as chills sweating)
Muscle aches or body aches
Unusual Fatigue
Headache
New loss of taste or smell
Congestion or runny nose
Nausea or vomiting
Diarrhea
When did your symptoms first appear (MM/DD/YYYY)
Did the infection require hospitalizations?
No
Yes
Unknown
Do you live in a long-term care facility, nursing home, homeless shelter, or housing at an institute of higher education?
No
Yes
Have you been tested for Covid-19 in the last 10 days?
No
Yes
What were the results of your previous test?
Negative
Positive
Are you currently pregnant?
No
Yes
Is this your first test for Covid-19?
No
Yes
Unknown
Was the patient admitted to intensive care unit (ICU) for Covid-19?
No
Yes
Unknown
Previous
Next
CGM
Current medications.
Add More
Do you have diabetes?
Yes
No
Unknown
What type of diabetes do you have?
Type 1
Type 2
Pre-Diabetes
Unknown
Do you currently use a blood glucose meter?
Yes
No
Unknown
On average how many times per day do you test your blood glucose levels?
What type of glucose do you use?
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Next
Peanut Allergy
Do you have a known or suspected allergy to peanuts?
Yes
No
Have you had an anaphylactic reaction due to peanuts?
Yes
No
Do you have allergies to other foods besides peanuts?
Yes
No
What kind?
Previous
Next
Peanut Allergy DTC
Has the individual been introduced to foods containing peanut?
Yes
No
Has the individual seen an allergist?
Yes
No
Has the individual been diagnosed with a peanut allergy in the past?
Yes
No
Has the individual been prescribed an epinephrine device for a peanut allergy?
Yes
No
Please list any diagnostic tests done in the past for a peanut allergy evaluation.
Our nurses will reach out to request a full list of the test results. You can also skip this step for now.
Was an Oral Food Challenge (OFC) conducted?
Yes
No
Has the individual been avoiding foods containing peanut?
Yes
No
Are you satisfied with your current peanut allergy treatment plan?
Yes
No
Does the individual have any other food allergies?
Yes
No
Does the individual have asthma?
Yes
No
Does the individual have eczema?
Yes
No
Has the individual been diagnosed with eosinophilic esophagitis?
Yes
No
Does the individual have any other medical conditions?
Please type 'N/A' if the individual does not have any other medical conditions.
Is the individual on Allergy Immunotherapy for environmental allergies?
Yes
No
Is the individual on any medications?
Yes
No
Current medications.
Add More
Is there any anxiety surrounding the diagnosis or treatment of food allergies for the individual or family member of the individual?
Yes
No
Has the individual been the target of teasing or aggressive behavior due to their food allergy?
Yes
No
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Emergency Contact
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Phone
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Relationship
Father
Mother
Brother
Sister
Son
Daughter
Half-brother
Half-sister
Grandfather
Grandmother
Grandson
Granddaughter
Aunt
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Niece
Nephew
First Cousin Male
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Great-grandfather
Great-grandmother
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Great-Aunt
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Father
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Half-brother
Half-sister
Grandfather
Grandmother
Grandson
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Aunt
Uncle
Niece
Nephew
First Cousin Male
First Cousin Female
Great-grandfather
Great-grandmother
Great-grandson
Great-granddaughter
Great-Aunt
Great-Uncle
Caregiver
Spouse
Domestic Partner
Patient requests to be assigned to a physician, via telemedicine service, as the primary provider for this test request.
Patient requests to be assigned to a physician, via telemedicine service, if their PCP does not respond to the test request
Patient requests test review by PCP only
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PCP last Name
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PCP NPI
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PCP Phone
PCP Fax
PCP Address
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