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Health Assessment
Health Assessment
Personal Information
What is today's date?
What is your name?
Please provide a contact number.
Please provide an email address.
Have you completed a JaxCareConnect Patient Questionnaire?
Yes
No
I am not sure
Personal Characteristics
Are you Hispanic or Latino?
Yes
No
I prefer not to answer
Which race(s) are you? Check all that apply.
Asian
Native Hawaiian
American Indian/Alaskan Native
Black/African American
I choose not to answer
Other
If you chose other, please enter your answer here:
Which gender do you identify with?
Woman
Man
Non-binary/gender nonconforming
Transgender
I prefer not to answer
Other
If you chose other, please enter your answer here:
Do you think of yourself as:
Straight/Heterosexual
Lesbian or Gay
Bisexual
Queer, Pansexual, and/or Questioning
I don't know
I prefer not to answer
Other
If you chose other, please enter your answer here:
Have you ever served in the United States Armed Forces?
Yes
No
I prefer not to answer
Other
If you chose other, please enter your answer here:
What language are you most comfortable speaking?
English
Spanish
Other
If you chose other, please enter your answer here:
Family and Home
Other than yourself, how many family members do you live with?
What is your housing situation today?
I live in a home where I rent, contribute to rent or own
I have shelter where I couch surf, stay with family/friends or stay in a car or van
I stay in a hotel
I stay in a public shelter (homeless or transitional housing facility)
I prefer not to answer
Are you worried about losing your housing?
Yes
No
I prefer not to answer
Are you the parent or legal guardian for a child/children under 18 years of age?
Yes
No
I prefer not to answer
Would you be interested in learning about free child care (birth to 5) and/or insurance/medical care opportunities for children?
Yes
No
I prefer not to answer
Money and Resources
What is the highest level of school that you have finished?
Less than a high school diploma
High school diploma or equivalent
Some college or trade school
College or trade graduate
I prefer not to answer
Other
If you chose other, please enter your answer here:
What is your current work situation
Full time work
Self-employed or gig work
Part time or temporary
Unemployed but seeking work
Unemployed but not seeking work
I prefer not to answer
Other
If you chose other, please enter your answer here:
What is your main health insurance?
I do not currently have insurance
Medicaid
Private health insurance
Public health insurance
Other
If you chose other, please enter your answer here:
In the past 12 months, how often have you used the emergency room for non-emergency care?
Not at all
1 or 2 times
More than 3 times
I prefer not to answer
Other
If you chose other, please enter your answer here:
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? Check all that apply.
Food
Clothing
Utilities
Medicine or any health care (prescriptions, mental, vision, dental)
Phone access
Rent payments
Child care
Not applicable
Other
If you chose other, please enter your answer here:
Has lack of transportation kept you from medical appointments, meetings, work, or from getting things you need for daily living?
Yes
No
I prefer not to answer
Social and Emotional Health
Overall, my emotional state:
impacts my day to day life due to emotional problems
affects my moods and creates persistent problems with functioning but not severely
is periodically unstable, but is a normal response to life situations
I prefer not to answer
Other
If you chose other, please enter your answer here:
Stress is when someone feels tense, nervous, anxious, or can’t sleep at night because their mind is troubled. How stressed are you?
Not at all
A little stressed
Very stressed
Extremely stressed
I prefer not to answer
Other
If you chose other, please enter your answer here:
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)
Less than once a week
Once or twice a week
Three times a week or more
I prefer not to answer
Other
If you chose other, please enter your answer here:
Who are the people or groups you usually see or talk to at times when you need support?
General Health and Lifestyle
Would you be interested in learning about free Covid-19 vaccinations, prevention methods and/or test sites?
--None--
Yes
No
Prefer not to answer
How true for you in the following statement: A primary care physician can play an important role in my long-term health outcomes
Yes this is true for me
No this is not true for me
I am not sure if this is true
I prefer not to answer
Other
If you or a loved one were experiencing a minor illness like a sore throat today, where are you most likely to seek care:
In the Emergency Room
At an Urgent Care Center
With a Primary Care doctor
I would not seek care
I prefer not to answer
Other
Please select the frequency in which you are exercising or engaging in physical activity weekly:
Not at all
Once per week
One to three times per week
More than three times per week
I prefer not to answer
Other
If you chose other, please enter your answer here:
I eat a healthy, balanced diet that incorporates fresh fruits and vegetables daily.
Yes
No
I could do better
I prefer not to answer
Other
If you chose other, please enter your answer here:
Are you a smoker?
Yes
No
I prefer not to answer
Are you exposed to second hand smoke on a regular basis?
Yes
No
I prefer not to answer
When is the last time you have been to the dentist?
Within the past 6 months
Within the past year
It's been more than a year
It's been more than 3 years
I can't remember
I prefer not to answer
Other
If you chose other, please enter your answer here:
Do you have any current medical needs?
Additional Questions
In the past year have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?
Yes
No
I prefer not to answer
Have you experienced time in the state foster care system as a dependent?
Yes
No
I prefer not to answer
Are you a refugee?
Yes
No
I prefer not to answer
Do you feel physically and emotionally safe where you currently live?
Yes
No
I prefer not to answer
In the past year, have you been afraid of your partner or ex-partner?
Yes
No
I prefer not to answer
Additional Notes Section
Submit Referral
Personal Information
What is your name?
Please provide a contact number.
Would you like to recieve SMS alerts?
YES!
By checking this box you are consenting to receive text message alerts several times per month. Messaging and data rates apply.View our
privacy policy
.
Please provide an email address.
Have you completed a JaxCareConnect Patient Questionnaire?
Yes
No
I am not sure
Personal Characteristics
Are you a US Citizen?:
--None--
Yes
No
Prefer not to answer
If not, what country were you born in?:
Date of entry into the US:
What is your current immigration status?:
--None--
Lawfully Residing/Green Card
Work Visa
Student Visa
No Current Documentation
Other
Prefer not to answer
Other Status:
Are you Hispanic or Latino?
Yes
No
I prefer not to answer
Which race(s) are you? Check all that apply.
Asian
Native Hawaiian
American Indian/Alaskan Native
Black/African American
I choose not to answer
Other
If you chose other, please enter your answer here:
Which gender do you identify with?
Woman
Man
Non-binary/gender nonconforming
Transgender
I prefer not to answer
Other
If you chose other, please enter your answer here:
Do you think of yourself as:
Straight/Heterosexual
Lesbian or Gay
Bisexual
Queer, Pansexual, and/or Questioning
I don't know
I prefer not to answer
Other
If you chose other, please enter your answer here:
Have you ever served in the United States Armed Forces?
Yes
No
I prefer not to answer
Other
If you chose other, please enter your answer here:
What language are you most comfortable speaking?
English
Spanish
Other
If you chose other, please enter your answer here:
Family and Home
Other than yourself, how many family members do you live with?
What is your housing situation today?
I live in a home where I rent, contribute to rent or own
I have shelter where I couch surf, stay with family/friends or stay in a car or van
I stay in a hotel
I stay in a public shelter (homeless or transitional housing facility)
I prefer not to answer
Are you worried about losing your housing?
Yes
No
I prefer not to answer
Are you the parent or legal guardian for a child/children under 18 years of age?
Yes
No
I prefer not to answer
Would you be interested in learning about free child care (birth to 5) and/or insurance/medical care opportunities for children?
Yes
No
I prefer not to answer
Money and Resources
What is the highest level of school that you have finished?
Less than a high school diploma
High school diploma or equivalent
Some college or trade school
College or trade graduate
I prefer not to answer
Other
If you chose other, please enter your answer here:
What is your current work situation
Full time work
Self-employed or gig work
Part time or temporary
Unemployed but seeking work
Unemployed but not seeking work
I prefer not to answer
Other
If you chose other, please enter your answer here:
What is your main health insurance?
I do not currently have insurance
Medicaid
Private health insurance
Public health insurance
Other
If you chose other, please enter your answer here:
In the past 12 months, how often have you used the emergency room for non-emergency care?
Not at all
1 or 2 times
More than 3 times
I prefer not to answer
Other
If you chose other, please enter your answer here:
Have you been unable to get any of the following?:
For windows: Hold down the control (ctrl) button to select multiple options. For Mac: Hold down the command button to select multiple options.
Food
Clothing
Utilities
Rx, mental, vision, or dental care
Phone access
Rent payments
Child care
Not applicable
Other
If you chose other, please enter your answer here:
Has lack of transportation kept you from medical appointments, meetings, work, or from getting things you need for daily living?
Yes
No
I prefer not to answer
Social and Emotional Health
Overall, my emotional state:
impacts my day to day life due to emotional problems
affects my moods and creates persistent problems with functioning but not severely
is periodically unstable, but is a normal response to life situations
I prefer not to answer
Other
If you chose other, please enter your answer here:
Stress is when someone feels tense, nervous, anxious, or can’t sleep at night because their mind is troubled. How stressed are you?
Not at all
A little stressed
Very stressed
Extremely stressed
I prefer not to answer
Other
If you chose other, please enter your answer here:
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)
Less than once a week
Once or twice a week
Three times a week or more
I prefer not to answer
Other
If you chose other, please enter your answer here:
Who are the people or groups you usually see or talk to at times when you need support?
General Health and Lifestyle
To your knowledge, have you ever been diagnosed with one of the following illnesses?:
For windows: Hold down the control (ctrl) button to select multiple options. For Mac: Hold down the command button to select multiple options.
COPD
Diabetes
Heart Disease
Kidney Disease
Long Haul Covid
Would you be interested in learning about free Covid-19 vaccinations, prevention methods and/or test sites?
--None--
Yes
No
Prefer not to answer
How true for you in the following statement: A primary care physician can play an important role in my long-term health outcomes
Yes this is true for me
No this is not true for me
I am not sure if this is true
I prefer not to answer
Other
If you or a loved one were experiencing a minor illness like a sore throat today, where are you most likely to seek care:
In the Emergency Room
At an Urgent Care Center
With a Primary Care doctor
I would not seek care
I prefer not to answer
Other
Please select the frequency in which you are exercising or engaging in physical activity weekly:
Not at all
Once per week
One to three times per week
More than three times per week
I prefer not to answer
Other
If you chose other, please enter your answer here:
I eat a healthy, balanced diet that incorporates fresh fruits and vegetables daily.
Yes
No
I could do better
I prefer not to answer
Other
If you chose other, please enter your answer here:
Are you a smoker?
Yes
No
I prefer not to answer
If yes, are you interested in free smoking cessation materials?:
--None--
Yes
No
Are you exposed to second hand smoke on a regular basis?
Yes
No
I prefer not to answer
When is the last time you have been to the dentist?
Within the past 6 months
Within the past year
It's been more than a year
It's been more than 3 years
I can't remember
I prefer not to answer
Other
If you chose other, please enter your answer here:
Do you have any current medical needs?
Additional Questions
In the past year have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?
Yes
No
I prefer not to answer
If yes, would you like to learn about additional resources?
--None--
Yes
No
Have you experienced time in the state foster care system as a dependent?
Yes
No
I prefer not to answer
Are you a refugee?
Yes
No
I prefer not to answer
Do you feel physically and emotionally safe where you currently live?
Yes
No
I prefer not to answer
In the past year, have you been afraid of your partner or ex-partner?
Yes
No
I prefer not to answer
Additional Notes Section
Submit Referral
2024 FEDERAL POVERTY LEVELS
Size of
Household
150%
monthly
150%
yearly
200%
monthly
200%
yearly
250%
monthly
250%
yearly
1
$1,883
$22,596
$2,510
$30,120
$3,138
$37,656
2
$2,555
$30,660
$3,407
$40,880
$4,259
$51,108
3
$3,228
$38,736
$4,303
$51,640
$5,379
$64,548
4
$3,900
$46,800
$5,200
$62,400
$6,500
$78,000
5
$4,573
$54,876
$6,097
$73,160
$7,621
$91,452
6
$5,245
$62,940
$6,993
$83,920
$8,741
$104,892
7
$5,918
$71,016
$7,890
$94,680
$9,863
$118,356
8
$6,590
$79,080
$8,787
$105,440
$10,984
$131,808
