Help Us Fill the Pantry! Question Title * 1. Have you taken any times from the Pantry in the past or today? Yes No; skip to Question 5. Question Title * 2. If you answered YES to Question 1, what items have you taken? Select all that apply. Any food items (canned food, cereal, pasta) Hygiene items (soap, shampoo, body wash, toothpaste, toothbrush) Baby food and formula Question Title * 3. How frequently are these items usually needed in your household? Weekly Every 2 weeks Monthly Every 3 months Question Title * 4. Why is the Pantry helpful for you? Convenience Cost is $0 or more expensive at stores Items are needed in my household An item was used during a visit at WMC (medical visit, health coaching, pharmacy) Other (please specify) Question Title * 5. In the last 3 months, did you get food or personal items at churches, food banks, or other organizations? Yes No Question Title * 6. What are the names of any organizations outside of WMC that provide personal items or food that you know of? We would like to contact them to possibly partner! Question Title * 7. Write your name and phone number below if you would like to talk with our Health Coach and learn more about community assistance or resources available to you. Done