-- phpMyAdmin SQL Dump
-- version 5.2.0
-- https://www.phpmyadmin.net/
--
-- Host: 127.0.0.1:3310
-- Generation Time: May 09, 2023 at 01:20 PM
-- Server version: 10.4.24-MariaDB
-- PHP Version: 8.1.6

SET SQL_MODE = "NO_AUTO_VALUE_ON_ZERO";
START TRANSACTION;
SET time_zone = "+00:00";


/*!40101 SET @OLD_CHARACTER_SET_CLIENT=@@CHARACTER_SET_CLIENT */;
/*!40101 SET @OLD_CHARACTER_SET_RESULTS=@@CHARACTER_SET_RESULTS */;
/*!40101 SET @OLD_COLLATION_CONNECTION=@@COLLATION_CONNECTION */;
/*!40101 SET NAMES utf8mb4 */;

--
-- Database: `medicaid`
--

-- --------------------------------------------------------

--
-- Table structure for table `form_details`
--

CREATE TABLE `form_details` (
  `form_id` int(11) NOT NULL,
  `first_name` varchar(200) DEFAULT NULL,
  `last_name` varchar(200) DEFAULT NULL,
  `nursing_home_name` varchar(200) DEFAULT NULL,
  `medicaid_date` varchar(200) DEFAULT NULL,
  `medicaid_community` varchar(100) DEFAULT NULL,
  `medicaid_id` varchar(200) DEFAULT NULL,
  `home_street_address` varchar(200) DEFAULT NULL,
  `home_street_address_line` varchar(200) DEFAULT NULL,
  `home_city` varchar(200) DEFAULT NULL,
  `home_state_region_province` varchar(200) DEFAULT NULL,
  `home_postal_zipcode` varchar(200) DEFAULT NULL,
  `snf_living` varchar(100) DEFAULT NULL,
  `snf_prior_street_address` varchar(200) DEFAULT NULL,
  `snf_prior_street_address_line` varchar(200) DEFAULT NULL,
  `snf_prior_city` varchar(200) DEFAULT NULL,
  `snf_prior_state_region_province` varchar(200) DEFAULT NULL,
  `snf_prior_zipcode` varchar(200) DEFAULT NULL,
  `spouse` varchar(200) DEFAULT NULL,
  `demographics_veteran` varchar(200) DEFAULT NULL,
  `demographics_have` varchar(200) DEFAULT NULL,
  `demographics_filled` varchar(200) DEFAULT NULL,
  `employment_status` varchar(200) DEFAULT NULL,
  `vechicles_currently_own` varchar(100) NOT NULL DEFAULT 'no',
  `vechicles_renting` varchar(100) NOT NULL DEFAULT 'no',
  `vechicles_sold_past_five_year` varchar(100) NOT NULL DEFAULT 'no',
  `vechicles_rent_free` varchar(100) NOT NULL DEFAULT 'no',
  `vechiclesown_rental_property` varchar(100) NOT NULL DEFAULT 'no',
  `vechicles_other_land` varchar(100) NOT NULL DEFAULT 'no',
  `how_much_rent` varchar(200) DEFAULT NULL,
  `pay_for_water` varchar(200) DEFAULT NULL,
  `vechicles_equity_value` varchar(200) DEFAULT NULL,
  `vehicles_own` varchar(100) NOT NULL DEFAULT 'no',
  `vehicles_sold` varchar(100) DEFAULT 'no',
  `vehicles_na` varchar(100) NOT NULL DEFAULT 'no',
  `make_a_model` varchar(200) DEFAULT NULL,
  `fair_market` varchar(200) DEFAULT NULL,
  `vehicles_date_sold` varchar(200) DEFAULT NULL,
  `sold_property_house_address` varchar(200) DEFAULT NULL,
  `sold_property_house_fair_value` varchar(200) DEFAULT NULL,
  `sold_property_house_sale_price` varchar(200) DEFAULT NULL,
  `sold_property_house_date_sold` varchar(200) DEFAULT NULL,
  `sold_property_second_house_address` varchar(200) DEFAULT NULL,
  `sold_property_second_house_fair_value` varchar(200) DEFAULT NULL,
  `sold_property_second_house_sale_price` varchar(200) DEFAULT NULL,
  `sold_property_second_house_date_sold` varchar(200) DEFAULT NULL,
  `name_homeowners_insurance` varchar(200) DEFAULT NULL,
  `insurance_medicare` varchar(100) NOT NULL DEFAULT 'no',
  `insurance_medicare_replacement` varchar(100) NOT NULL DEFAULT 'no',
  `insurance_through_work` varchar(100) NOT NULL DEFAULT 'no',
  `insurance_medigap` varchar(100) NOT NULL DEFAULT 'no',
  `insurance_life_insurance` varchar(100) NOT NULL DEFAULT 'no',
  `insurance_none` varchar(100) NOT NULL DEFAULT 'no',
  `medicare_insurance` varchar(200) DEFAULT NULL,
  `hmo_name_id` varchar(200) DEFAULT NULL,
  `medicare_life_insurance` varchar(200) DEFAULT NULL,
  `medicare_cash_value` varchar(200) DEFAULT NULL,
  `medicare_policy` varchar(200) DEFAULT NULL,
  `social_security_income_payer` varchar(200) DEFAULT NULL,
  `social_security_income_amount` varchar(200) DEFAULT NULL,
  `social_security_income_frequency` varchar(200) DEFAULT NULL,
  `income_pension_payer_name` varchar(200) DEFAULT NULL,
  `income_pension_amount` varchar(200) DEFAULT NULL,
  `income_pension_frequency` varchar(200) DEFAULT NULL,
  `income_second_pension_payer` varchar(200) DEFAULT NULL,
  `income_second_pension_amount` varchar(200) DEFAULT NULL,
  `income_second_pension_frequency` varchar(200) DEFAULT NULL,
  `income_annuity_payer_name` varchar(200) DEFAULT NULL,
  `income_annuity_amount` varchar(200) DEFAULT NULL,
  `income_annuity_frequency` varchar(200) DEFAULT NULL,
  `income_distribution_payer` varchar(200) DEFAULT NULL,
  `income_distribution_amount` varchar(200) DEFAULT NULL,
  `income_stock_payer` varchar(200) DEFAULT NULL,
  `income_stock_amount` varchar(200) DEFAULT NULL,
  `income_stock_frequency` varchar(200) DEFAULT NULL,
  `income_trust_name` varchar(200) DEFAULT NULL,
  `income_trust_garantor` varchar(200) DEFAULT NULL,
  `income_trust_trustee` varchar(200) DEFAULT NULL,
  `income_trust_amount` varchar(200) DEFAULT NULL,
  `spouse_social_security_income_payer` varchar(200) DEFAULT NULL,
  `spouse_social_security_income_amount` varchar(200) DEFAULT NULL,
  `spouse_social_security_income_frequency` varchar(200) DEFAULT NULL,
  `spouse_income_pension_payer_name` varchar(200) DEFAULT NULL,
  `spouse_income_pension_amount` varchar(200) DEFAULT NULL,
  `spouse_income_pension_frequency` varchar(200) DEFAULT NULL,
  `spouse_income_second_pension_payer` varchar(200) DEFAULT NULL,
  `spouse_income_second_pension_amount` varchar(200) DEFAULT NULL,
  `spouse_income_second_pension_frequency` varchar(200) DEFAULT NULL,
  `spouse_income_annuity_payer_name` varchar(200) DEFAULT NULL,
  `spouse_income_annuity_amount` varchar(200) DEFAULT NULL,
  `spouse_income_annuity_frequency` varchar(200) DEFAULT NULL,
  `spouse_income_distribution_payer` varchar(200) DEFAULT NULL,
  `spouse_distribution_amount` varchar(200) DEFAULT NULL,
  `spouse_income_distribution_frequency` varchar(200) DEFAULT NULL,
  `spouse_income_stock_payer` varchar(200) DEFAULT NULL,
  `spouse_income_stock_amount` varchar(200) DEFAULT NULL,
  `spouse_income_stock_frequency` varchar(200) DEFAULT NULL,
  `spouse_income_trust_name` varchar(200) DEFAULT NULL,
  `spouse_income_trust_garantor` varchar(200) DEFAULT NULL,
  `spouse_income_trust_trustee` varchar(200) DEFAULT NULL,
  `spouse_income_trust_amount` varchar(200) DEFAULT NULL,
  `investments_stocks_company_name` varchar(200) DEFAULT NULL,
  `Investments_stocks_approx_value` varchar(200) DEFAULT NULL,
  `Investments_bonds_company_name` varchar(200) DEFAULT NULL,
  `Investments_bonds_approx_value` varchar(200) DEFAULT NULL,
  `Investments_annuity_company_name` varchar(200) DEFAULT NULL,
  `Investments_annuity_approx_value` varchar(200) DEFAULT NULL,
  `investments_ira_company_name` text DEFAULT NULL,
  `investments_ira_approx_value` text DEFAULT NULL,
  `investments_company_name_spouse` text DEFAULT NULL,
  `Investments_approx_value_spouse` text DEFAULT NULL,
  `bonds_company_name_spouse` text DEFAULT NULL,
  `bonds_approx_value_spouse` text DEFAULT NULL,
  `annuity_company_name_spouse` text DEFAULT NULL,
  `annuity_approx_value_spouse` text DEFAULT NULL,
  `ira_company_name_spouse` text DEFAULT NULL,
  `ira_approx_value_spouse` text DEFAULT NULL,
  `banking_any_bank_accounts_past_5_years` varchar(50) NOT NULL DEFAULT 'no',
  `banking_bank_1_bank` text DEFAULT NULL,
  `banking_bank_1_account` text DEFAULT NULL,
  `bank_1_amount` text DEFAULT NULL,
  `bank_1_date_closed` text DEFAULT NULL,
  `bank_2_bank` text DEFAULT NULL,
  `bank_2_account` text DEFAULT NULL,
  `bank_2_amount` text DEFAULT NULL,
  `bank_2_date_closed` text DEFAULT NULL,
  `bank_3_bank` text DEFAULT NULL,
  `bank_3_account` text DEFAULT NULL,
  `bank_3_amount` text DEFAULT NULL,
  `bank_3_date_closed` text DEFAULT NULL,
  `any_bank_accounts_past_5_years` varchar(50) DEFAULT 'no',
  `spouse_banking_1_bank` text DEFAULT NULL,
  `spouse_banking_1_account` text DEFAULT NULL,
  `spouse_banking_1_amount` text DEFAULT NULL,
  `spouse_banking_1_date_closed` text DEFAULT NULL,
  `spouse_banking_2_bank` text DEFAULT NULL,
  `spouse_banking_2_account` text DEFAULT NULL,
  `spouse_banking_2_amount` text DEFAULT NULL,
  `spouse_banking_2_date_closed` text DEFAULT NULL,
  `spouse_banking_3_bank` text DEFAULT NULL,
  `spouse_banking_3_account` text DEFAULT NULL,
  `spouse_banking_3_amount` text DEFAULT NULL,
  `spouse_banking_3_date_closed` text DEFAULT NULL,
  `you_have_irrevocable_prepaid` varchar(50) DEFAULT 'no',
  `funeral_home_name` text DEFAULT NULL,
  `funeral_home_price` text DEFAULT NULL,
  `you_have_irrevocable_prepaid_for_spouse` varchar(50) DEFAULT 'no',
  `spouses_first_name` text DEFAULT NULL,
  `spouses_last_name` text DEFAULT NULL,
  `spouses_ss` text DEFAULT NULL,
  `spouse_dob` date DEFAULT NULL,
  `best_contact_first_name` text DEFAULT NULL,
  `best_contact_last_name` text DEFAULT NULL,
  `email_id` varchar(50) DEFAULT NULL
) ENGINE=InnoDB DEFAULT CHARSET=utf8;

--
-- Indexes for dumped tables
--

--
-- Indexes for table `form_details`
--
ALTER TABLE `form_details`
  ADD PRIMARY KEY (`form_id`);

--
-- AUTO_INCREMENT for dumped tables
--

--
-- AUTO_INCREMENT for table `form_details`
--
ALTER TABLE `form_details`
  MODIFY `form_id` int(11) NOT NULL AUTO_INCREMENT;
COMMIT;

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/*!40101 SET CHARACTER_SET_RESULTS=@OLD_CHARACTER_SET_RESULTS */;
/*!40101 SET COLLATION_CONNECTION=@OLD_COLLATION_CONNECTION */;
