YES
NO
1
Do you have health insurance/Medicaid for your children?
• For your family
• For yourself
2
Do you need a doctor for your children?
• For your family
• For yourself
3
Do you need a dentist for your children?
• For your family
• For yourself
4
Are you or any of your family members experiencing any of the following such as (depression, high levels of stress, anxiety, uncontrolled anger, major life changes etc.)?
5
Are immunizations / shots up to date for all your children?
6
Do you have concerns about the following for any of your children or yourself: Hearing?
• Vision
• Speech
• Physical Coordination
7
Would you like information on healthy foods and healthy weight?
8
Do you ever worry about the effect of alcohol and drugs on your family or yourself?
9
If you are pregnant, do you have pre-natal care? (You may skip this question if it doesn't apply.)
10
Do you have difficulty getting prescriptions / medicines for your family or yourself?
11
Do you have questions about starting a family?
12
Do you want to prevent future pregnancy and need information about birth control?
13
Would you like information to assess your risk for contracting sexually transmitted diseases (STD's)?
14
Do you have a working smoke detector in the home?
15
Do you have transportation when you need it?
16
Do you feel unsafe in your home?
• In your neighborhood
17
Have you moved more than three times in the last two years?
18
Do your children have a safe place to play?
19
Do you need legal assistance related to taking care of your children?
20
Does your home have running water?
21
Do you need help with utilities in your home such as: Gas?
• What about electricity
• What about water
• What about phone service
22
Do any of the following family members need to learn how to swim: Children?
• Family members other than children
• Yourself
23
Do you need car seats for your children?
24
Do you need a place to live?
25
Do you usually run out of money before your food, shelter or clothing needs are met?
26
Do you need information for yourself or your child(ren) about: Job Placement?
• Vocational Training
• GED Preparation
• Alternative Education
• English as a Second Language Training
• College Level Courses
27
Does your young child like to be hugged and comforted?
28
Do you have any concerns about the behavior of any of your children?
29
Do you need childcare or youth programs for any of your children?
30
Do you feel your child is learning and developing as well as other children their age?
31
Would you like more information on parenting?
32
Are books for young children available to you?
33
Would you like help reading to your child?
34
Do you feel you have the skills to help your child do well in school?
35
Do you take time for your spiritual or emotional needs?
36
Are you interested in faith-based programs to overcome challenges in your life, such as divorce, substance abuse, etc?
37
Are you interested in participating in faith-based organizations?
38
Do you want information about activities in your community for your children and your family?
39
Are you experiencing any family loss or trauma due to divorce, separation, death, domestic violence, etc?
40
If you have any other needs not mentioned above, would you like to be contacted by a Whole Child Advisor to help you?
A-21
Do you have a gynecologist?
A-22
Do you have a dentist?
A-23
Do you have Health Insurance?
A-24
In the last year have you had a doctor's visit?
A-25
In the last year have you had a Regular Check-Up?
A-26
In the last year have you had a Pap Smear?
A-27
In the last year have you had a Breast Exam?
A-28
In the last year have you had a Cholesterol Test?
A-29
In the last year have you had a Blood Pressure Check?
A-30
Have you ever been concerned that you might have a sexually transmitted disease?
A-31
Do you have diabetes, high blood pressure, or asthma?
A-32
Are you trying to get pregnant?
A-33
Have you waited two years before trying again?
A-34
Do you smoke?
A-35
Do others think you use too much alcohol or other drugs?
A-36
Are you feeling burnt out?
A-37
Are you happy with your weight?
A-38
Do you exercise at least 3 times per week?
A-39
Do your daily meals include fruits and vegetables?
A-40
In the last year, has anyone hit you or tried to hurt you?
A-41
Is your BMI greater than 25? To find out, enter your information into the table below and press calculate.
Adults
List each adult living in your household on the rows provided below.
First Name
Middle Name
Last Name
Suffix
Sex
Employment Status
Race / Ethnicity
Person Completing Profile
Adult 1
- Male Female
-
Full-time
Part-time
Student
Unemployed
Disabled
Other
-
African American
Asian
Caucasian
Hispanic
Native American
Other
Adult 2
-
Male
Female
-
Full-time
Part-time
Student
Unemployed
Disabled
Other
-
African American
Asian
Caucasian
Hispanic
Native American
Other
Adult 3
-
Male
Female
-
Full-time
Part-time
Student
Unemployed
Disabled
Other
-
African American
Asian
Caucasian
Hispanic
Native American
Other
Adult 4
-
Male
Female
-
Full-time
Part-time
Student
Unemployed
Disabled
Other
-
African American
Asian
Caucasian
Hispanic
Native American
Other
Adult 5
-
Male
Female
-
Full-time
Part-time
Student
Unemployed
Disabled
Other
-
African American
Asian
Caucasian
Hispanic
Native American
Other
Children
List each child living in your household on the rows provided below. Please list the youngest child first.
First Name
Middle Name
Last Name
Suffix
Sex
Date of Birth
Race / Ethnicity
Child 1
-
Male
Female
- 1 2 3 4 5 6
