Section 1 of 4
Jo's Help Patient Questionnaire
Couponingmom1992@gmail.com
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Section 4 of 4
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1001 bass rd
1001 bass rd
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Macon
Macon
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31210
31210
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Ga
Ga
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4783360552
4783360552
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Please describe the patient situation, needs, and assistance required.
Please describe the patient situation, needs, and assistance required.
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My son, mom and self. Who in your family is affected by cancer?
My son, mom and self. Who in your family is affected by cancer?
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Has your diagnosis caused financial strain?
Has your diagnosis caused financial strain?
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Yes, I’m the head of household
Yes, I’m the head of household
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Are there needs not met by healthcare insurance?
Are there needs not met by healthcare insurance?
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Do you travel long distances for your appointments?
Do you travel long distances for your appointments?
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Have funds for gas and/or groceries been effected due to cancer-related expenses? Yes I lost my home and job
Have funds for gas and/or groceries been effected due to cancer-related expenses? Yes I lost my home and job
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Have you had to miss an appointment due to finances?
Have you had to miss an appointment due to finances?
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Have you exhausted family and local resources? Yes
Have you exhausted family and local resources? Yes
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No, I have a mom with Alzheimer’s and I have a 12 yr old son to take care of
No, I have a mom with Alzheimer’s and I have a 12 yr old son to take care of
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Absolutely.
Absolutely.
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If applicable, please describe any past assistance given (including date, cost, travel expenses, etc.)
If applicable, please describe any past assistance given (including date, cost, travel expenses, etc.)
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