We Care SurveyLegal Name*Home addressEmail*LanguageGender*MaleFemaleDate of Birth*Phone Number*Ethnicity*HispanicNon-HispanicOtherEducation Status*High SchoolAssociate DegreeBachelorsMastersDidn't Finish High SchoolMartial Status*MarriedUnmarriedLocation you first seen by AMCCLongwoodSanfordBithloDown Town OrlandoDate you first seen by AMCCSplitter11.What is your housing situation today?I Have housingI don't have housingI have housing today, but I am worried about losing housing in the future2.Within the past 12 months,you worried that your food would run out before you got money to buy more?Often trueSometimes trueNever True3. Do you have issues with transportation to get to our clinic located in Longwood?YesNo4.Are you getting any government assistance? If yes, please specifyYesNo5. Are you currently on a medication assistance program? If yes, where do you get your medication?YesNo6.Do you have children under the age of 18?YesNo7.Which assistance do you need the most?FoodClothingHousingOther8.Do you need any social services assistance? If yes, please specify.YesNo9. Were we able to answer all your questions at our clinic?YesNo10. What is your healthy lifestyle goal?Eat HealthierGet regular physical activityAchieve/Maintain a healthy weightBe free of dependence on tobacco, illicit drugs, or alcoholMaintain a cheerful, hopeful outlook on lifeSubmit Error occured. Please confirm your data and submit again:
