Please use this form to help find what you need!
What is your full name?
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First Name
Last Name
What is your date of birth?
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Month
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Day
Year
Date
Sex
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Female
todays date
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Month
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Day
Year
Date
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When we locate resources, how should we contact you?
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Let's get started with a few questions
Do you have access to a park or places for recreation?
Almost Always
Most of the time
Some of the time
Never
Do you need help with transportation to get to your doctor’s appointments?
Almost Always
Most of the time
Some of the time
Never
Do you ever need help filling out medical forms, reading prescription labels, understanding how to take your pills, or following doctors’ instructions?
Almost Always
Most of the time
Some of the time
Never
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Are there others in your family or support system who should be informed and consulted regarding your medical care?
Yes
No
What is their name?
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What is their relationship to you?
Please Select
Mother
Father
Brother
Sister
Grandparent
Spouse
Other
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How often do you skip doses or forget to take medicines prescribed to you?
Almost Always
Most of the time
Some of the time
Never
Does your family have access to a quality education and job opportunities?
Almost Always
Most of the time
Some of the time
Never
Do you have access to fresh fruits and vegetables?
Almost Always
Most of the time
Some of the time
Never
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Do you feel that your physical health is affecting your spiritual life?
Almost Always
Most of the time
Some of the time
Never
Do you go back to your native country or visit other foreign countries to have medical treatments, buy medicine or obtain specific herbal remedies?
Almost Always
Most of the time
Some of the time
Never
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Do you have enough money to buy the things you need to live everyday such as food, clothing, housing, and/or utilities?
Almost Always
Most of the time
Some of the time
Never
Do you see a native healer or non-traditional practitioner (curandero, espiritista, santero) when you feel ill?
Almost Always
Most of the time
Some of the time
Never
Are you able to get medical care when you need it?
Almost Always
Most of the time
Some of the time
Never
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Does anyone in your family have problems with substance or alcohol abuse?
Almost Always
Most of the time
Some of the time
Never
Do you feel discriminated, bullied against, or isolated at work/school/community?
Almost Always
Most of the time
Some of the time
Never
Do you take non-prescribed herbal folk medicine for your medical conditions or general health?
Almost Always
Most of the time
Some of the time
Never
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