We Ask Because We Care

And this can improve overall access to healthcare.” Question and Response Values Do you identify as a person with disability? ❑ Yes ❑ No ❑ If you wish, please specify ❑ Do not know ❑ Prefer not to answer Could you benefit from support related to any of the following? (Check all that apply) ❑ Alzheimer's Disease/Dementia ❑ Autism Spectrum Disorder ❑ Chronic Illness (e.g. [...] Your provider may use this to refer you to resources that can help you access medicine or medical supplies.” Question and Response Values In the past 12 months, were you unable to get medicine or medical supplies, or did you do anything to make them last longer because of the cost? ❑ Yes ❑ No ❑ Not applicable, I did not have to get any medicine or medical supplies in the past 12 months ❑ Do not kn. [...] ❑ Do not know ❑ Prefer not answer Who do you live with? Select all that apply: ❑ Parent(s) or Guardian(s) ❑ Spouse or Partner ❑ Child(ren) ❑ Grandparent (s) ❑ Sibling(s) ❑ Other family ❑ Friends or Roommates ❑ Paid caregiver or attendant ❑ Alone ❑ Other (Please Specify):______ ❑ Prefer not to answer In the past 12 months, was there a time when you were not able to pay the mortgage or rent on time?. [...] Script “We may use this information to refer you to social resources and social supports that may be helpful to you.” Question and Response Values Do you feel you have people who you can open up to or confide in? ❑ Yes, I always or sometimes have someone ❑ No, I don't have anyone ❑ Do not know ❑ Prefer not to answer Do you have people to rely on if you needed help? ❑ Yes, I always or sometimes hav. [...] ❑ English ❑ French ❑ Amharic ❑ Arabic ❑ Bengali ❑ Braille ❑ Chinese (Simplified) ❑ Chinese (Traditional) ❑ Czech ❑ Dari ❑ Farsi ❑ Greek ❑ Hindi ❑ Hungarian ❑ Italian ❑ Karen ❑ Korean ❑ Nepali ❑ Polish ❑ Portuguese ❑ Punjabi ❑ Russian ❑ Serbian ❑ Slovak ❑ Somali ❑ Spanish ❑ Tagalog ❑ Tamil ❑ Tigrinya ❑ Turkish ❑ Twi ❑ Ukrainian ❑ Urdu 23 ❑ Vietnamese ❑ Other (please specify) ❑ Prefer not to answer.