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Enfomasyon pèsonèl
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Kijan ou rele?
Tanpri bay yon nimewo kontak.
Tanpri bay yon adrès imèl.
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Wi
Non
mwen pa si
Karakteristik pèsonèl
Èske ou se Panyòl oswa Latino?
Wi
Non
Mwen prefere pa reponn
Ki ras ou ye? Tcheke tout sa ki aplike.
Azyatik
Natif natal Awayi
Ameriken Endyen / Alaska natif natal
Nwa/Afriken Ameriken
Mwen chwazi pa reponn
Lòt
Si ou te chwazi lòt, tanpri antre repons ou isit la:
Avèk ki sèks ou idantifye?
Fanm
Monchè
Ki pa Peye-binè / sèks nonconforming
Transganr
Mwen prefere pa reponn
Lòt
Si ou te chwazi lòt, tanpri antre repons ou isit la:
Èske ou panse nan tèt ou tankou:
Dwat / Etewoseksyèl
Madivin oswa masisi
Biseksyèl
Queer, Pansexual, ak / oswa Kesyon
M pa konnen
Mwen prefere pa reponn
Lòt
Si ou te chwazi lòt, tanpri antre repons ou isit la:
Èske w te janm sèvi nan Fòs Lame Etazini yo?
Wi
Non
Mwen prefere pa reponn
Lòt
Si ou te chwazi lòt, tanpri antre repons ou isit la:
Ki lang ou pi alèz pou pale?
Angle
Panyòl
Lòt
Si ou te chwazi lòt, tanpri antre repons ou isit la:
Fanmi ak Kay
Lòt pase tèt ou, konbyen manm fanmi ou ap viv avèk yo?
Ki sitiyasyon lojman ou jodi a?
Mwen rete nan yon kay kote mwen lwe, kontribye nan lwaye oswa posede
Mwen gen abri kote mwen kanape navige, rete ak fanmi / zanmi oswa rete nan yon machin oswa kamyonèt
Mwen rete nan yon otèl
Mwen rete nan yon abri piblik (sanzabri oswa lojman tranzisyonèl)
Mwen prefere pa reponn
Èske ou enkyete w sou pèdi lojman ou a?
Wi
Non
Mwen prefere pa reponn
Èske ou se paran oswa gadyen legal pou yon timoun / timoun ki poko gen 18 an?
Wi
Non
Mwen prefere pa reponn
Èske ou ta enterese nan aprann sou swen pou timoun gratis (nesans jiska 5) ak / oswa asirans / opòtinite swen medikal pou timoun yo?
Wi
Non
Mwen prefere pa reponn
Lajan ak Resous
Ki pi wo nivo lekòl ou fini?
Mwens pase yon diplòm lekòl segondè
Diplòm lekòl segondè oswa ekivalan
Gen kèk kolèj oswa lekòl komès
Kolèj oswa gradye komès
Mwen prefere pa reponn
Lòt
Si ou te chwazi lòt, tanpri antre repons ou isit la:
Ki sitiyasyon travay ou ye kounye a
Travay a plen tan
Travay endepandan oswa travay gig
A tan pasyèl oswa tanporè
Chomaj men kap chèche travay
Chomaj men pa chèche travay
Mwen prefere pa reponn
Lòt
Si ou te chwazi lòt, tanpri antre repons ou isit la:
Ki prensipal asirans sante ou?
Mwen pa gen asirans kounye a
Medicaid
Asirans sante prive
Asirans sante piblik
Lòt
Si ou te chwazi lòt, tanpri antre repons ou isit la:
Nan 12 mwa ki sot pase yo, konbyen fwa ou te itilize sal ijans lan pou swen ki pa ijan?
Pa ditou
1 oswa 2 fwa
Plis pase 3 fwa
Mwen prefere pa reponn
Lòt
Si ou te chwazi lòt, tanpri antre repons ou isit la:
Nan ane ki sot pase a, èske ou menm oswa nenpòt manm fanmi w ap viv avèk yo pa t 'kapab jwenn nenpòt nan bagay sa yo lè li te reyèlman bezwen? Tcheke tout sa ki aplike.
Manje
Rad
Itilite
Medikaman oswa nenpòt swen sante (preskripsyon, mantal, vizyon, dantè)
Telefòn aksè
Peman lwaye
Swen pou timoun
Pa aplikab
Lòt
Si ou te chwazi lòt, tanpri antre repons ou isit la:
Èske mank transpò anpeche w pran randevou medikal, reyinyon, travay, oswa pou w pa jwenn bagay ou bezwen pou w viv chak jou?
Wi
Non
Mwen prefere pa reponn
Sante sosyal ak emosyonèl
An jeneral, eta emosyonèl mwen:
enpak lavi mwen an jou akòz pwoblèm emosyonèl
afekte atitid mwen ak kreye pwoblèm ki pèsistan ak fonksyone, men se pa grav
se detanzantan enstab, men se yon repons nòmal nan sitiyasyon lavi yo
Mwen prefere pa reponn
Lòt
Si ou te chwazi lòt, tanpri antre repons ou isit la:
Estrès se lè yon moun santi l tansyon, nève, enkyete, oswa li pa ka dòmi lannwit paske lespri yo boulvèse. Kijan ou strese?
Pa ditou
Yon ti kras ensiste
Trè ensiste
Trè ensiste
Mwen prefere pa reponn
Lòt
Si ou te chwazi lòt, tanpri antre repons ou isit la:
Konbyen fwa ou wè oswa pale ak moun ke ou pran swen ak santi w tou pre? (Pou egzanp: pale ak zanmi nan telefòn lan, vizite zanmi oswa fanmi, ale nan legliz oswa reyinyon klib)
Mwens pase yon fwa pa semèn
Yon fwa oswa de fwa nan yon semèn
Twa fwa pa semèn oswa plis
Mwen prefere pa reponn
Lòt
Si ou te chwazi lòt, tanpri antre repons ou isit la:
Ki moun ki moun yo oswa gwoup ou konn wè oswa pale ak yo nan fwa lè ou bezwen sipò?
Jeneral Sante ak Lifestyle
Èske w ta enterese aprann sou vaksen gratis Covid-19, metòd prevansyon ak/oswa sit tès yo?
--Okenn--
Wi
Non
Pito pa reponn
Ki jan vre pou ou nan deklarasyon sa a: Yon doktè swen prensipal ka jwe yon wòl enpòtan nan rezilta sante alontèm mwen
Wi sa vre pou mwen
Non sa a pa vre pou mwen
Mwen pa sèten si sa a se vre
Mwen prefere pa reponn
Lòt
Si oumenm oswa yon moun ou renmen an t ap sibi yon ti maladi tankou yon gòj fè mal jodi a, ki kote ou gen plis chans pou w chèche swen:
Nan Sal Ijans la
Nan yon Sant Swen Ijan
Avèk yon doktè Swen Prensipal
Mwen pa ta chèche swen
Mwen prefere pa reponn
Lòt
Tanpri chwazi frekans kote ou ap fè egzèsis oswa angaje nan aktivite fizik chak semèn:
Pa ditou
Yon fwa pa semèn
Youn a twa fwa pa semèn
Plis pase twa fwa pa semèn
Mwen prefere pa reponn
Lòt
Si ou te chwazi lòt, tanpri antre repons ou isit la:
Mwen manje yon rejim alimantè ki an sante, ekilibre ki enkòpore fwi ak legim fre chak jou.
Wi
Non
Mwen te kapab fè pi byen
Mwen prefere pa reponn
Lòt
Si ou te chwazi lòt, tanpri antre repons ou isit la:
Èske ou se yon fimè?
Wi
Non
Mwen prefere pa reponn
Èske ou ekspoze a lafimen dezyèm men sou yon baz regilye?
Wi
Non
Mwen prefere pa reponn
Ki dènye fwa ou te kay dantis la?
Nan 6 mwa ki sot pase yo
Nan ane ki sot pase a
Li te plis pase yon ane
Sa fè plis ke 3 zan
Mwen pa ka sonje
Mwen prefere pa reponn
Lòt
Si ou te chwazi lòt, tanpri antre repons ou isit la:
Èske w gen nenpòt bezwen medikal kounye a?
Lòt Kesyon
Nan ane ki sot pase a ou te pase plis pase 2 nwit afile nan yon prizon, prizon, sant detansyon, oswa etablisman koreksyonèl jivenil?
Wi
Non
Mwen prefere pa reponn
Eske ou te fè eksperyans tan nan sistèm swen adoptif eta a kòm yon depandan?
Wi
Non
Mwen prefere pa reponn
Èske w se yon refijye?
Wi
Non
Mwen prefere pa reponn
Èske w santi w an sekirite fizikman ak emosyonèlman kote w ap viv kounye a?
Wi
Non
Mwen prefere pa reponn
Nan ane ki sot pase a, èske ou te pè patnè ou oswa ansyen patnè ou?
Wi
Non
Mwen prefere pa reponn
Lòt Seksyon Nòt
Soumèt Referans
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
