Peehip wellness form 2026

1. Click ‘Get Form’ to open the peehip wellness form in the editor.
2. Begin with Section 1, where you will enter your Contract Number and Social Security Number (SSN) of the person being screened. Ensure to print clearly using a black ink pen.
3. Fill in the Screen Date and select the appropriate options for Gender and Contract Holder/Spouse. Provide your Daytime Phone Number, Last Name, and First Name.
4. Indicate if screening was not performed due to reasons such as Pregnancy or Disability. Then, choose your race/ethnicity from the provided options.
5. Answer questions regarding any medical conditions like High Cholesterol, High Blood Pressure, or Diabetes, and indicate if you take medication for these conditions.
6. Section 2 is to be completed by your healthcare provider. They will fill in details such as Blood Pressure, Blood Glucose, Total Cholesterol, Height, Weight, Waist measurements, and whether tobacco products were used in the last 12 months.
7. Finally, ensure that your healthcare provider signs and provides their information before submitting the form via fax or mail to the ADPH Wellness Program.

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