Sacramento Street Medicine Health Research Initiative Question Title * 1. Date of outreach Date / Time Date Time AM/PM - AM PM Question Title * 2. Are you a patient of Sacramento Street Medicine Yes No Question Title * 3. If yes, full name or patient number Question Title * 4. If yes to the question above, how many times have you had a consult with an SSM provider this year? 1-2 3-4 5-6 7-8 9+ Question Title * 5. If yes, to your knowledge, has SSM decreased hospital visits Yes No Unsure Question Title * 6. Age Under 18 18-24 25-34 35-44 45-54 55-64 65+ Question Title * 7. Race White Black or African American Hispanic or Latino Asian or Asian American American Indian or Alaska Native Native Hawaiian or other Pacific Islander Another race Question Title * 8. Gender Female Male Non-binary Other Question Title * 9. Camp Location Gold Blue Purple Green Silver Orange Question Title * 10. If patient: Chief complaint today Question Title * 11. Do you have insurance? Yes No Unsure Question Title * 12. If yes, who is your insurance carrier Kaiser Molina Anthem Healthnet Unknown Other (please specify) Question Title * 13. Do you have a primary care provider? Yes No Unknown Question Title * 14. If yes, how many times did you see your PCP this year? 1 2 3 4 5 More than 5 Question Title * 15. Who is your PCP/Medical home Elica Health Center Wellspace OneCommunity Kaiser SNAC Unknown Other (please specify) Question Title * 16. For non-patients: how many times have you had a consult with an SSM provider this year? 0 1 3 4 5+ Question Title * 17. How many Emergency Department visits in the past year 0 1-2 3-4 5-6 7-8 9+ Question Title * 18. Number of hospitalizations in the last year 0 1 2 3 4 5+ Question Title * 19. Reason for hospitalization CHF COPD Wound care Trauma/Assault Substance us Mental Health Illness Other (please specify) Question Title * 20. What hospital was used Kaiser Mercy General Sutter General Methodist hospital UC Davis Emergency Department Mercy San Juan Other (please specify) Question Title * 21. Do you have a Case Worker Yes No Question Title * 22. Do you have a history of any of following chronic conditions Hypertension (high blood pressure) Congestive heart failure Psychiatric disorders (such as bipolar disorder or schizophrenia) COPD and/or Asthma Depression Other (please specify) None of the above Question Title * 23. Internal note (do not ask) :Resources used for Medical and/or Basic Outreach Wound care provided wound care supplies provided Point of care glucose test STD testing Vitals Pregnancy test COVID-19 Rapid Antigen Test Medication Dispensed Prescription HbA1C Urinanlysis Lab draw Referral for diagnostic imaging Other (please specify) None of the above Question Title * 24. What are your thoughts on Street Medicine compared to traditional clinics or hospitals? Question Title * 25. For patients: document blood pressure reads Done