Client Health Questionnaire First NameEmail* What is your primary health concern (for you or family)?High blood Pressure, Diabetes, Thyroid (Chronic Needs)ceInfections (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 ago1-3 years agoOver 3 years agoWhere 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?YesNoDo you need help with any of the following?Housing (Homeless or at risk of homelessness)FoodAbuseJob Assistance (Finding a job, higher wage job)HealthcareAddiction/RecoveryWhat Healthcare Services do you not have access to, that you wish you had access to?Urgent CarePrimary Care (Blood pressure, Diabetes)Dental ServicesVision CareWomen’s HealthPediatric CareMental HealthAre you currently participating in free/reduced meals through your child’s school?I do not have childrenYesNo and I am NOT interested in learning moreNo but I am interested in learning moreAre you currently receiving SNAP benefits?YesNoAre you interested in learning more about SNAP benefits?YesNo
