Client Health Questionnaire

First Name

Email*

What is your primary health concern (for you or family)?

When was the last time you visited a doctor?

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?

Do you have affordable medical insurance?

Do you need help with any of the following?

What Healthcare Services do you not have access to, that you wish you had access to?

Are you currently participating in free/reduced meals through your child’s school?

Are you currently receiving SNAP benefits?

Are you interested in learning more about SNAP benefits?