Health Information
PRAPARE: Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences
2016. National Association of Community Health Centers, Inc. and partners. All rights reserved.
Personal Characteristics
Are you Hispanic or Latino?
Which race(s) are you? Check all that apply *
At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?
Have you been discharged from the armed forces of the United States?
What language are you most comfortable speaking?
Family & Home
How many family members, including yourself, do you currently live with?
Your answer
What is your housing situation today?
Are you worried about losing your housing?
What address do you live at?
Your answer
Money & Resources
What is the highest level of school that you have finished?
What is your current work situation?
What is your main insurance?
During the past year, what was the total combined income for you and the family members you live with? This information will help us determine if you are eligible for any benefits.
Your answer
In the past year, have you or any family members you live with been unable to get any of the following when it was really needed? Check all that apply.
Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living? Check all that apply.
Social and Emotional Health
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)
Stress is when someone feels tense, nervous, anxious or can't sleep at night because their mind is troubled. How stressed are you?
Optional 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?
Are you a refugee?
Do you feel physically and emotionally safe where you currently live?
In the past year, have you been afraid of your partner or ex-partner?
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