-- phpMyAdmin SQL Dump
-- version 5.1.1
-- https://www.phpmyadmin.net/
--
-- Host: 127.0.0.1:3306
-- Generation Time: May 10, 2023 at 09:58 AM
-- Server version: 10.6.5-MariaDB
-- PHP Version: 7.4.27

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_distribution_frequency` text 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',
  `funeral_home_name_a` text DEFAULT NULL,
  `funeral_home_price_a` text DEFAULT NULL,
  `spouses_first_name` text DEFAULT NULL,
  `spouses_last_name` text DEFAULT NULL,
  `spouses_ss` text DEFAULT NULL,
  `spouse_dob` varchar(50) 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=utf8mb3;

--
-- Dumping data for table `form_details`
--

INSERT INTO `form_details` (`form_id`, `first_name`, `last_name`, `nursing_home_name`, `medicaid_date`, `medicaid_community`, `medicaid_id`, `home_street_address`, `home_street_address_line`, `home_city`, `home_state_region_province`, `home_postal_zipcode`, `snf_living`, `snf_prior_street_address`, `snf_prior_street_address_line`, `snf_prior_city`, `snf_prior_state_region_province`, `snf_prior_zipcode`, `spouse`, `demographics_veteran`, `demographics_have`, `demographics_filled`, `employment_status`, `vechicles_currently_own`, `vechicles_renting`, `vechicles_sold_past_five_year`, `vechicles_rent_free`, `vechiclesown_rental_property`, `vechicles_other_land`, `how_much_rent`, `pay_for_water`, `vechicles_equity_value`, `vehicles_own`, `vehicles_sold`, `vehicles_na`, `make_a_model`, `fair_market`, `vehicles_date_sold`, `sold_property_house_address`, `sold_property_house_fair_value`, `sold_property_house_sale_price`, `sold_property_house_date_sold`, `sold_property_second_house_address`, `sold_property_second_house_fair_value`, `sold_property_second_house_sale_price`, `sold_property_second_house_date_sold`, `name_homeowners_insurance`, `insurance_medicare`, `insurance_medicare_replacement`, `insurance_through_work`, `insurance_medigap`, `insurance_life_insurance`, `insurance_none`, `medicare_insurance`, `hmo_name_id`, `medicare_life_insurance`, `medicare_cash_value`, `medicare_policy`, `social_security_income_payer`, `social_security_income_amount`, `social_security_income_frequency`, `income_pension_payer_name`, `income_pension_amount`, `income_pension_frequency`, `income_second_pension_payer`, `income_second_pension_amount`, `income_second_pension_frequency`, `income_annuity_payer_name`, `income_annuity_amount`, `income_annuity_frequency`, `income_distribution_payer`, `income_distribution_amount`, `income_distribution_frequency`, `income_stock_payer`, `income_stock_amount`, `income_stock_frequency`, `income_trust_name`, `income_trust_garantor`, `income_trust_trustee`, `income_trust_amount`, `spouse_social_security_income_payer`, `spouse_social_security_income_amount`, `spouse_social_security_income_frequency`, `spouse_income_pension_payer_name`, `spouse_income_pension_amount`, `spouse_income_pension_frequency`, `spouse_income_second_pension_payer`, `spouse_income_second_pension_amount`, `spouse_income_second_pension_frequency`, `spouse_income_annuity_payer_name`, `spouse_income_annuity_amount`, `spouse_income_annuity_frequency`, `spouse_income_distribution_payer`, `spouse_distribution_amount`, `spouse_income_distribution_frequency`, `spouse_income_stock_payer`, `spouse_income_stock_amount`, `spouse_income_stock_frequency`, `spouse_income_trust_name`, `spouse_income_trust_garantor`, `spouse_income_trust_trustee`, `spouse_income_trust_amount`, `investments_stocks_company_name`, `Investments_stocks_approx_value`, `Investments_bonds_company_name`, `Investments_bonds_approx_value`, `Investments_annuity_company_name`, `Investments_annuity_approx_value`, `investments_ira_company_name`, `investments_ira_approx_value`, `investments_company_name_spouse`, `Investments_approx_value_spouse`, `bonds_company_name_spouse`, `bonds_approx_value_spouse`, `annuity_company_name_spouse`, `annuity_approx_value_spouse`, `ira_company_name_spouse`, `ira_approx_value_spouse`, `banking_any_bank_accounts_past_5_years`, `banking_bank_1_bank`, `banking_bank_1_account`, `bank_1_amount`, `bank_1_date_closed`, `bank_2_bank`, `bank_2_account`, `bank_2_amount`, `bank_2_date_closed`, `bank_3_bank`, `bank_3_account`, `bank_3_amount`, `bank_3_date_closed`, `any_bank_accounts_past_5_years`, `spouse_banking_1_bank`, `spouse_banking_1_account`, `spouse_banking_1_amount`, `spouse_banking_1_date_closed`, `spouse_banking_2_bank`, `spouse_banking_2_account`, `spouse_banking_2_amount`, `spouse_banking_2_date_closed`, `spouse_banking_3_bank`, `spouse_banking_3_account`, `spouse_banking_3_amount`, `spouse_banking_3_date_closed`, `you_have_irrevocable_prepaid`, `funeral_home_name`, `funeral_home_price`, `you_have_irrevocable_prepaid_for_spouse`, `funeral_home_name_a`, `funeral_home_price_a`, `spouses_first_name`, `spouses_last_name`, `spouses_ss`, `spouse_dob`, `best_contact_first_name`, `best_contact_last_name`, `email_id`) VALUES
(7, 'dsgr', 'dfgfg', NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, 'no', 'no', 'no', 'no', 'no', 'no', NULL, NULL, NULL, 'no', 'no', 'no', NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, 'no', 'no', 'no', 'no', 'no', 'no', NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, 'no', NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, 'no', NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, 'no', NULL, NULL, 'no', NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL),
(9, '$mediciad_first_name', '$mediciad_last_name', '$nursing_home_name', '$medicaid_date', '$Medicaid_yes', '$medicaid_id_z', '$home_street_address', '$home_street_address_line', '$home_city', NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, 'no', 'no', 'no', 'no', 'no', 'no', NULL, NULL, NULL, 'no', 'no', 'no', NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, 'no', 'no', 'no', 'no', 'no', 'no', NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, 'no', NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, 'no', NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, 'no', NULL, NULL, 'no', NULL, NULL, NULL, NULL, NULL, NULL, NULL, NULL, '$email_id'),
(10, 'last', 'first', 'test', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '1', '', '', '', '', '', '', '', '', '', '', '', '', '1', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', NULL, '', '', 'test@gmail.com'),
(11, 'last', 'first', 'test', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '1', '', '', '', '', '', '', '', '', '', '', '', '', '1', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', 'test@gmail.com'),
(12, 'Sports', 'club', 'test', '2023-05-10', '1', 'medica', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '1', '', '', '', '', '', '', '', '', '', '', '', '', '1', '', '', '', '', '', '', '', '', '', '', '', '', '1', '', '', '', '', '', '', '', '', '', 'Sports', 'club', 'sportsclub2022@gmail.com'),
(13, 'Sports', 'club', 'test', '2023-05-10', '1', 'vbn', 'tigaon', 'sdfg', 'faridabad', 'Haryana', '121101', '1', 'tigaon', 'dgvfd', 'faridabad', 'Haryana', '121101', 'yes', 'Have a disabled child living at home', 'Have a disabled child living at home', 'Filed taxes in the past 4 years', 'currently_working', 'Yes', '1', 'Sold/Transferred in the past 5 years', 'Yes', 'Yes', 'Yes', 'drfgbh', 'fghnbg', 'k', '1', '1', '', 'k', 'hg', '2023-05-10', 'a', 'as', 'sd', 'gfdg', 'a', 'as', 'fg', 'fg', 'dcvd', '1', '1', '1', '1', '1', '1', '', '', '', '', '', 'f', '', '', 'f', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', 'fdg', 'fdg', '', '', '', '', '', '', '', '', 'f', '', '', '', '', 'fgb', 'f', '', '', '', '', 'zdg', 'fd', 'f', 'fxz', 'cgj', '', 'jgcj', '', 'gjg', '', 'gcjc', '', 'cj', 'gcjg', 'gj', 'gjh', 'ghj', 'gjg', 'ffbghhffg', 'gfhng', '1', '', '', '', '', 'gcvhjnhgvb', '', '', '', '', '', '', '', '1', '', '', '', '', 'bmjh', 'hm', '', '', '', 'hmm', 'mhm', 'hmhj', '1', 'nbm', '', '1', 'nbm', 'm', 'gn', 'ghnjhg', 'nm', '2023-05-10', 'gjhnLast Name', 'Last Name', 'sportsclub2022@gmail.com');

--
-- 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, AUTO_INCREMENT=14;
COMMIT;

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