| 93025-5 |
Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE] |
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| Indent93043-8 |
Personal Characteristics |
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| Indent Indent56051-6 |
Are you Hispanic or Latino? |
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| Indent Indent32624-9 |
Which race(s) are you? |
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| Indent Indent93035-4 |
At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income? |
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| Indent Indent93034-7 |
Have you been discharged from the armed forces of the United States? |
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| Indent Indent54899-0 |
What language are you most comfortable speaking? |
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| Indent93042-0 |
Family & Home |
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| Indent Indent63512-8 |
How many family members, including yourself, do you currently live with? |
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{#} |
| Indent Indent71802-3 |
What is your housing situation today? |
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| Indent Indent93033-9 |
Are you worried about losing your housing? |
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| Indent Indent56799-0 |
What address do you live at? |
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| Indent93041-2 |
Money & Resources |
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| Indent Indent82589-3 |
What is the highest level of school that you have finished? |
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| Indent Indent67875-5 |
What is your current work situation? |
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| Indent Indent76437-3 |
What is your main insurance? |
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| Indent Indent63586-2 |
During the past year, what was the total combined income for you and the family members you live with? This information will help us determine if you are eligible for any benefits. |
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/a |
| Indent Indent93031-3 |
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? |
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| Indent Indent93030-5 |
Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living? |
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| Indent93040-4 |
Social & Emotional Health |
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| Indent Indent93029-7 |
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)? |
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| Indent Indent93038-8 |
Stress is when someone feels tense, nervous, anxious or can't sleep at night because their mind is troubled. How stressed are you? |
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| Indent93039-6 |
Optional Additional Questions |
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| Indent Indent93028-9 |
In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility? |
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| Indent Indent93027-1 |
Are you a refugee? |
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| Indent Indent93026-3 |
Do you feel physically and emotionally safe where you currently live? |
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| Indent Indent76501-6 |
In the past year, have you been afraid of your partner or ex-partner? |
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