Healthcare Access Assessment Form
Please complete this form to help us assess your healthcare access needs.
Full Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Do you currently have health insurance?
Yes
No
Prefer not to say
Primary Healthcare Provider Name
How often do you visit a healthcare provider?
Weekly
Monthly
Every 3-6 months
Yearly
Rarely
Never
What barriers do you face in accessing healthcare?
Please describe any other barriers or concerns regarding healthcare access.
Submit
Should be Empty: