Social Determinants of Health: 5 questions - ACHC (PRAPARE)

Thank you for helping us to learn more about the needs in our communities, and about the potential gaps in social resources.

We estimate it takes 2 minutes to answer these five brief (but important) questions.

The answers you provide here are completely anonymous (unless you choose to include your contact information at the end).

We appreciate your help. We need to know where to focus our efforts toward increasing local resources.

Thank you, Asher Community Health Center

Question Title

* 1. TRANSPORTATION: In the past 12 months, has lack of transportation kept you from getting to medical appointments, meetings, work or from getting things needed for daily living?

Yes, its kept me from medical things, like travel to medical appointments or getting medications.

Yes, its kept me from non-medical things (but has not kept me from medical appointments or getting medications).

No.

Decline to answer.

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* 2. Living Situation: What is your living situation today?

I have a steady place to live.

I have a place to live today, but I am worried about losing it in the future.

I do not have a steady place to live (I am temporarily staying with others, or in a shelter, or in a motel/hotel, or outside on the streets or a park, or living out of my car/vehicle, or in some other insecure place).

Decline to answer.

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* 3. Food - Q 1: Within the past 12 months, were you worried that your food would run out before you got money to buy more?

Often true.

Sometimes true.

Never true.

Decline to answer.

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* 4. Food - Q 2: Within the past 12 months, did you buy food that didn't last long enough, and you didn't have money to get more?

Often true.

Sometimes true.

Never true.

Decline to answer.

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* 5. Financial Resources: How hard is it for you to pay for the very basics like food, housing, heating, medical care and medications?

Not hard at all.

Somewhat hard.

Very hard.

Decline to answer.

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* 6. Would you like someone from Asher Community Health Center to contact you regarding resources that may be available?
If so, please enter your name and any of your contact information below - or call 971-245-3249 (direct line) to reach the ACHC Community Health Worker Joan Field.
"We care about your health, and also about your quality of life."

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Social Determinants of Health: 5 questions - ACHC (PRAPARE)

Question Title

* 1. TRANSPORTATION: In the past 12 months, has lack of transportation kept you from getting to medical appointments, meetings, work or from getting things needed for daily living?

Question Title

* 2. Living Situation: What is your living situation today?

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* 3. Food - Q 1: Within the past 12 months, were you worried that your food would run out before you got money to buy more?

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* 4. Food - Q 2: Within the past 12 months, did you buy food that didn't last long enough, and you didn't have money to get more?

Question Title

* 5. Financial Resources: How hard is it for you to pay for the very basics like food, housing, heating, medical care and medications?

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* 7. Do you have any additional comments?