My Own Health Report

In the past 7 days, how often were you sleepy during the daytime

Never

Rarely

Sometimes

Often

Always

Have you used tobacco in the last 30 days?

Smoked:

Yes

Used a Smokeless Tobacco Product:

Yes

How many times in the past year have you used an illegal drug or prescription medication for non-medical reasons?

Never

1-3 times

4 or more times

In general, would you say your health is:

Excellent

Very Good

Good

Fair

Poor

How concerned are you that you will not have a place to live sometime in the next 6 months?

Not concerned

Somewhat

Very

How often do you have access to transportation?

Never

Rarely

Some of the time

All the time

In the past 6 months, how often did the food you bought not last, and you didn't have money to buy more?

Never

Sometimes

Often

Do you ever have difficulties making ends meet at the end of the month?

Yes

When was your last dental appointment?

Less than a year ago

1-2 years ago

Greater than 2 years ago

Do you feel safe in your neighborhood?

Yes

Are you ever afraid that your spouse/partner or another person you live with might hurt you?

Yes

Where are you living today?

Homeless

Shelter

With a friend or family member

Home/Apartment

Other

Are you at risk of losing your housing?

Yes

During any part of the year, have you had trouble paying for medications, clinic visits, and or medical supplies?

Yes

The next questions are about how you feel about different aspects of your life. For each one, mark how often you feel that way

How often do you feel that you lack companionship?

Hardly Ever

Some of the time

Often

How often do you feel left out?

Hardly Ever

Some of the time

Often

How often do you feel isolated from others?

Hardly Ever

Some of the time

Often

Health Risk Assessment

Over the past 7 days:

Over the past 2 weeks, how often have you been bothered by these problems below?

Over the past 2 weeks, how often have you been bothered by these problems below?

Over the past 2 weeks, how often have you been bothered by these problems below?

Over the past 2 weeks, how often have you been bothered by these problems below?

Over the past 2 weeks, how often have you been bothered by these problems below?

Over the past 2 weeks, how often have you been bothered by these problems below?

Have you used tobacco in the last 30 days?

Basic information