1.Have you taken any times from the Pantry in the past or today?

Yes

No; skip to Question 5.

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

3.How frequently are these items usually needed in your household?

Weekly

Every 2 weeks

Monthly

Every 3 months

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)

5.In the last 3 months, did you get food or personal items at churches, food banks, or other organizations?

Yes

No

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!

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.