FIRST NAME     LASTNAME

EMAIL   PHONE 

BEST TIME TO CALL

1. DO YOU HAVE ANY LIFE INSURANCE?  YES  NO
2.  DO YOU HAVE ANY HEALTH INSURANCE?  YES  NO
3. DO YOU HAVE ANY Prescription drug coverage?  YES NO
4. ARE YOU CONCERNED ABOUT YOUR MONTHLY BUDGET?  YES NO
5. ARE YOU STILL WORKING? YES NO
6.  ARE YOU CONCERNED ABOUT LOSING YOUR JOB? YES   NO 
7. ARE YOU CONCERNED ABOUT RISING FOOD AND FUEL PRICES? YES NO
8. ARE YOU RETIRED OR SEMI RETIRED? YES NO
9. ARE YOU DISABLED?  YES NO
10. WOULD YOU LIKE TO GET SOME HELP?  YES NO

 COMMENTS OR QUESTIONS

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