Demographics
Age What is your age?
___ Age in years
___ Don’t’ know /Not sure
Race/ethnic Are you Hispanic or Latino?
___ Yes ___ No
___ Don’t’ know /Not sure
Which one or more of the following would you say is your race? ___ White
___ Black or African-American ___ Asian
___ Native Hawaiian or Other Pacific Islander ___ American Indian or Alaska Native
___ Mixed race (please specify) _____________ ___ Other (please specify) ____________ ___ Don’t’ know /Not sure
Marital status Are you…?
___ Married ___ Divorced ___ Widow ___ Separate
___ Single (never been married) ___ A member of an unmarried couple
Education What is the highest grade or year of school you completed?
___ Never attended school or only attended kindergarten ___ Grades 1 through 8 (Elementary)
___ Grades 9 through 11 (Some high school) ___ Grade 12 or GED (High school graduate)
___ College 1 year to 3 years (Some college and technical school) ___ College 4 years or more (College graduates)
Children How many children do you have? ____
List their ages and who they are staying with (with you, with family, with friends, foster care, adopted by another family member?)
Ages Who are they staying with? (you, family,
friends, foster care, adopted by another family member) ____ __________________ ____ __________________ ____ __________________ ____ __________________ ____ __________________ ____ __________________ ____ __________________
Employment status Are you currently …?
___ Employed for wages ___ Self-employed
___ Out of work for more than 1 year ___ Out of work for less than 1 year ___ Unable to work
If you are employed, are you…? ___ Part time
___ Full time
Health status How would you describe your health?
____ Excellent ____ Very good ____ Good ____ Fair ____ Poor
___ Don’t know / Not sure
Health Care Access
Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare or Medicaid?
___ Yes ___ No
___ Don’t’ know /Not sure
Was there a time in past 12 months when you needed to see a doctor but could not because of cost?
___ Yes ___ No
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Where do you go for health care? ____ Doctor’s office
____ Public clinic ____ Emergency Room
____ I do not go anywhere for health care. ____ Other
How long ago did you have each of the following health check-ups? Mammogram ____ Less than 1 year
____ 1 to 2 years ____ 3-4 years ____ 5 or more years ____ Do not know/not sure Pap Test ____ Less than 1 year
____ 1 to 2 years ____ 3-4 years ____ 5 or more years ____ Do not know/not sure
About how long has it been since your last visit for a routine checkup?
Doctor ____ Less than 1 year ____ 1 to 2 years ____ 3-4 years ____ 5 or more years ____ Do not know/not sure Dentist ____ Less than 1 year
____ 1 to 2 years ____ 3-4 years ____ 5 or more years ____ Do not know/not sure Eye Doctor ____ Less than 1 year
____ 1 to 2 years ____ 3-4 years ____ 5 or more years ____ Do not know/not sure
What prevents you from getting health care? (check all that apply) ____ Lack of money ____ Lack of transportation ____ Unsure where to go ____ No childcare ____ Afraid or nervous
____ Don’t trust health care providers ____ Doctors
____ Nurses
____ Problems with language ____ Nothing
____ Other, please list ________________ _________________
Physical Health Have you been told by a doctor, nurse, or other health care
professional you have or had…?
Arthritis ____ Yes ___ No ___ Don’t know
Asthma ____ Yes ___ No ___ Don’t know
Cancer ____ Yes ___ No ___ Don’t know
Chronic bronchitis ____ Yes ___ No ___ Don’t know Diabetes (high sugar) ____ Yes ___ No ___ Don’t know Heart disease ____ Yes ___ No ___ Don’t know High blood pressure ____ Yes ___ No ___ Don’t know Sexually transmitted
diseases (STD) ____ Yes ___ No ___ Don’t know Ulcer Stomach ____ Yes ___ No ___ Don’t know Skin problems ____ Yes ___ No ___ Don’t know
Mental Health How many days has each of the following occurred in the past 2
weeks (the past 1 to 14 days)? Write the number of days you had. . . ____ Little interest or pleasure in doing things.
____ Felt down, depressed, or hopeless.
____ Trouble falling asleep or staying asleep or sleeping too much. ____ Felt tired or had little energy.
____ Poor appetite or eaten too much.
____ Felt bad about yourself or that you were a failure or let your family
down.
____ Trouble concentrating on things, such as reading a newspaper or watching TV.
____ Moved or spoken so slowly that other people could have noticed?
Or the opposite
____ Being so fidgety or restless that you were moving around a lot more than usual.
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Has a doctor or other healthcare provider EVER told you that you have or have had. . .
____ Anxiety disorder (including acute stress disorder, anxiety, generalized
anxiety disorder, obsessive-compulsive disorder, panic disorder,
phobia, posttraumatic stress disorder, or social anxiety disorder).
____Depressive disorder (including depression, major depression, dysthymia, or minor depression).
Tobacco Use Have you smoked at least 100 cigarettes in you entire life?
___ Yes ___ No
___ Never smoked ___ Don’t’ know /Not sure
Do you now smoke cigarettes every day, some days, or not at all? ___ Every day
___ Some days ___ Not at all ___ Never smoked ___ Don’t’ know /Not sure
During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?
___ Yes ___ No
___ Never smoked ___ Don’t’ know /Not sure
Homeless History Date you came to the shelter? _____________
What are the reasons for being homeless at this time? ____ Physical illness
____ Emotional or mental illness ____ Drugs/alcohol
____ Violence ____ Legal problems
____ Relationship problems/conflicts ____ Loss of job
____ Eviction/lack of money to pay rent ____ Other, please list _______________
Where did you live before coming to the shelter? ___ With family or friends for how long? _____ ___ My own apartment or house
for how long? _____
___ Hotel for how long? _____
___ On the street for how long? _____
___ In prison for how long? _____
___ Another shelter for how long? _____ Have you ever been homeless before:
___ Yes ____ No If so, when ________________
how long _____________
Were you in any type of foster care as a child? ___ Yes ____ No If so, when ________________ how long _____________ Emotional Support and Life Satisfaction
How often do you get the social and emotional support you need? ___ Always
___ Usually ___ Sometimes ___ Rarely ___ Never
___ Don’t know / Not sure
Veteran Status Have you ever served on active duty in the United States Armed
Forces, either in the regular military or in a National Guard or military reserve unit?
____ Yes ____ No