Survey canvas

1. Q1 · HRA-104Single Choice HIPAA

   How would you rate your overall physical health in the past 30 days?

   Excellent · Very good · Good · Fair · Poor
   Required for submission
2. Q2 · ACC-118Single Choice Internal

   Do you have reliable transportation to medical appointments?

   Yes · No · Sometimes
   Required for submission
3. Q3 · HRA-160Date Picker HIPAA

   When was your last annual wellness visit?
   Required for submission