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What's your first name?

What's your last name?

What's your email address?

1. Do you or someone in you live with have any of the following?

Age 65 years or above

Diabetes

Chronic Lung Disease

High Blood Pressure

Obesity (BMI 30+, calculate: https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm)

Kidney Disease

Serious Heart Disease (e.g., coronary artery disease, heart failure, cardiomyopathy)

Hemoglobin disorder (e.g.,, thalassemia, sickle cell disorder)

Other: