Age & Ethnicity
Date of Birth
Age:
Sex
SSN
Served in Armed Forces
U.S. Citizen
If Not, Has Legal Documentation
Race
Hispanic/Latino
Do you identify as Haitian?
1. Highest Level of Education
Household Members:Tell us who is in your family. A household consists of you (the client), your spouse, and any children 18 years of age and younger within your legal guardianship, including unborn children.
Number of people in your household:
11. Do you have a primary care doctor or healthcare provider? (A primary care doctor is a doctor who will see you for a checkup and sick visit).
11a. Who is your provider?
Please select a provider (if applicable) as well as type your provider if they are different. Thank you!
12. If you are sick or need medical advice, where do you go?
14. In the past 6 months, have you had any health problems?
15. Have you or any member of your family had cancer?
16. Currently, do you smoke cigarettes, cigars, pipes or use other tobacco products?
17. Have you smoked cigarettes in the last 15 years?
18. Do you smoke cigarettes?
20. How long have you been smoking cigarettes, or how long did you smoke cigarettes?
years
21. Have you had a CT scan of your lungs within the last 12 months?
22. Do you live in a house with a basement below ground level?
23. Has a doctor, nurse or other health professional ever told you that your have diabetes?
24. Has a doctor, nurse or other health professional ever told you that your have high blood pressure?
25. Has a doctor, nurse or other health professional ever told you that your cholesterol is high?
26. Women only: Are you pregnant?
27. Women only: Do you plan to become pregnant in the next year?
28. Women only: Do you still have your cervix?
28a. If no, was it removed due to cervical cancer or pre-cervical cancer?
29. Do you have a disability?