PRAPARE- Resource Questionnaire

At Great Mines Health Center, we want to make sure that we provide the best care and services possible to meet your needs. This information will help us determine if we need to add new services or programs to meet the needs of our patients. This information will be kept private and secure. Your decision to answer or to refuse to answer will NOT impact your ability to receive care. In many cases, this information will help us determine if you are eligible for any additional benefits, programs, or services.

NAME AND DOB REQUIRED

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* 1. First Name

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* 2. Last Name

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* 3. DOB (date of birth)?

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* 4. Phone Number

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* 5. Are you Hispanic or Latino?

Yes

I choose not to answer this question.

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* 6. Which race(s) are you?

White

Pacific Islander

Native Hawaiian

Black/African American

American Indian/Alaskan Native

I choose not to answer this question.

Other (please specify)

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* 7. At any point in the past 2 years, has season or migrant farm work been your or your family’s main source of income?

Yes

I choose not to answer this question

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* 8. What Language are you most comfortable speaking?

English

Spanish

I choose not to answer this question.

Other (please specify)

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* 9. Have you been discharged from the United States armed forces?

Yes

I choose no to answer this question.

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* 10. How many family members, including yourself, currently live in your home?

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* 11. What is your current housing situation?

I have housing.

I do not have housing. (living with others, homeless)

I choose not to answer this question.

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* 12. Are you worried about losing your housing?

Yes

I choose no to answer this question.

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* 13. What is the highest level of school that you have finished?

Less than high school degree

High school diploma or GED

More than high school

I choose no to answer this question.

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* 14. What is your current work situation?

Unemployed

Part-time

Full-time

Student

Retired

Disabled

Homemaker

I choose not to answer this question.

Other (please specify)

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* 15. During the past year, what was the total combined income for you and family members you live with? This information will help us determine if you are eligible for any benefits.

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* 16. In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?

Food

Clothing

Utilities

Child Care

Phone

Medicine or health services (medical, dental, mental health, vision)

I choose not to answer this question.

Other (please specify)

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* 17. Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?

Yes, it has kept me from medical appointments or from getting my medications.

Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I need.

All of the above.

I choose not to answer this question

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* 18. How often do you see or talk to people that you care about and feel close to? (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)

Less than once a week

1 or 2 times a week

3 to 5 times a week

5 or more times a week

I choose not to answer this question.

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* 19. Stress is when someone feels tense, nervous, anxious, or can’t sleep at night because their mind is troubled. How stressed are you?

Not at all

A little bit

Somewhat

Quite a bit

Very Much

I choose not to answer this question.

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* 20. In the past year, have you spent more than 2 nights in a row in jail, prison, detention center, or juvenile correction facility?

Yes

I choose not to answer this question.

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* 21. Are you a refugee?

Yes

I choose not to answer this question.

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* 22. Do you feel physically and emotionally safe where you currently live?

Yes

I choose not to answer this question.

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* 23. In the past year have you been afraid of your partner or ex-partner?

Yes

I choose not to answer this question.