Client Health Questionnaire First Name Email* What is your primary health concern (for you or family)? High blood Pressure, Diabetes, Thyroid (Chronic Needs)ce Infections (ear, eye, urine, skin), cold/flu, injuries (Urgent Care Needs) Well Checks (Primary Care) When was the last time you visited a doctor? Less than a year ago 1-3 years ago Over 3 years ago Where did you go the last time you visited a doctor or healthcare facility? For example urgent care, emergency room, general practitioner.Which of the following do you do on a daily basis? Drink 3 bottles of water Walk a mile Eat a meal with vegetables and fruits Drink alcohol (daily) Smoke Do you have affordable medical insurance? Yes No Do you need help with any of the following? Housing (Homeless or at risk of homelessness) Food Abuse Job Assistance (Finding a job, higher wage job) Healthcare Addiction/Recovery What Healthcare Services do you not have access to, that you wish you had access to? Urgent Care Primary Care (Blood pressure, Diabetes) Dental Services Vision Care Women’s Health Pediatric Care Mental Health Are you currently participating in free/reduced meals through your child’s school? I do not have children Yes No and I am NOT interested in learning more No but I am interested in learning more Are you currently receiving SNAP benefits? Yes No Are you interested in learning more about SNAP benefits? Yes No
