Health Equity Are there different non-perishable food items you would like to see available in the ARE food pantry? Are there different toiletry items (personal care and/or cleaning supplies you would like to see available in the ARE food pantry? For example, swiffer mops, toilet cleaner, skin or hair care products, organizational items, etc. What food items are most important to you to have at home? Do you feel that you have enough money each month to access food for you and/or your family?YesNoSometimesDo you have trouble accessing reliable transportation for your every day needs? If yes, please explain.If you have Medicaid, are you able to use Medicaid Transportation to get to medical appointments? If no, please explainDo you feel like you are able to make your health a priority right now? If no, please explainWhat is the most important thing for you in your life right now? Please explain.What are some of the biggest stressors that you have in your life right now? Please explain.Do you feel like your current living situation is safe and accessible? For instance, are you able to move up and down stairs easily, do you feel safe in your neighborhood; do you have house items to safely store food, clean clothes, access to shower/toilet, etc.? If no, please explain.Do you feel safe in your current housing and/or in your neighborhood? If no, please explain.Do you feel like you are able to get to your housing easily? (Are stairs/ramps available if you cannot use stairs, driveway/walkways easily accessible, etc.?) Do you have a refrigerator and working stove? If no, please explain the items you do not have. If you rent your current house/apartment, are you afraid of your property owner finding out your status? Not Applicable Yes No if yes, please explain What are your current housing needs, if any?Would you feel more comfortable with a Case Manager providing you services at ARE of your same (check all that apply): Age Race Gender Identity Ethnicity Spoken Language Sexual Orientation Disability History of Incarceration Level of Education Religious Beliefs Country of Origin None of the Above If yes, please explain. What do you need from your current Case Manager that you might not be getting now?What mental health needs do you currently have, if any?Do you feel like you have an active voice in the services you receive at ARE? For instance, do you feel that you can voice suggestions and concerns about service needs to your Case Manager/ARE Staff? Please explain.Do you feel like you understand your physician when they explain your lab results/medical conditions/medications? If no, please explain. If no, do you have someone that can attend appointments with you?Do you feel like you receive enough time to ask questions at your doctor's office? If no, please explain.Do you feel like you are treated respectfully when you are at the doctor's office? If no, please explain.Do you feel like you are treated respectfully at ARE offices? If no, please explain.Do you feel like you have access to care for preventable diseases that prevent you from repeat health issues/multiple hospitalizations? If no, please explain.Do you feel like you are able to make a livable wage at your job or if receiving SSI/SSDI? If no, please explain the barriers you are facing.Do you feel connected to the community you live in? For example, are you able to engage in community activities? Do you feel represented in your community based on (check all that apply): Age Race Gender Identity Ethnicity Spoken Language Sexual Orientation Disability History of Incarceration Level of Education Religious Beliefs Country of Origin Not Applicable None of the Above Please explain Do you ever fear accessing services in the community? For example: due to legal status, fear of stigma, difficulty navigating healthcare systems/insurance, etc. Yes No Please explain End of life issues and concerns can be difficult to think about and even more difficult to plan for, whether it be for a loved-one or for yourself. We would like to ask a few questions about end of life care, as it affects us all. What steps have you take to prepare for end of life care for yourself?What resources do you need to help you make end of life decisions or pay for end of life costs? Δ
