Osteopathic Family Medicine, LLC

Where we live, work, learn and play affects our health. You do not have to answer these questions, but they help us take care of you by understanding more about you. You can skip any question you prefer not to answer.

To help identify needs that our patients have that may affect their general mental or physical health, we are asking that all patients complete the following questionnaire annually. Thank you, Dr. Way

Last Name * First Name * Date of Birth * Over the last 6 months, have you been worried that you may not have a steady place to live? What is your living situation today? Over the last 6 months, have you worried about having enough money for food? Over the last 6 months, have you had trouble paying your heating or electricity bill? Do you ever have problems being able to afford everything you need? Over the last 6 months, have you needed help from another person or service animal with any daily activities, such as bathing, dressing, eating, or doing household chores? Do you ever have problems easily and safely moving around your home, or the place you live? In the last 6 months, have you had trouble getting transportation to medical appointments? In the last 6 months, have you been afraid of someone close to you? (Like a spouse, partner, ex, or family member) Do you feel your physical or emotional safety is at risk because of someone close to you? How often do you see or talk to people that you care about and feel close to? (Talking to friends on the phone or virtually, visiting friends/family, religious services, clubs) Would you like to get help with any of these needs? If you would like to explain any of your answers above please do so, here.