staying because of your physical health? Do you have any chronic health issues with your liver, kidneys, stomach, lungs or heart? Y N Refused Do you have any physical disabilities that would limit the type of housing you could Y N Refused access, or would make it hard to live independently because you’d need help? When you are sick or not feeling well, do you avoid getting help? Y N Refused Are you currently pregnant, have you ever been pregnant or have you ever gotten Y N N/A or Refused someone pregnant? Has your drinking or drug use led you to being kicked out of an apartment or program Y N Refused where you were staying in the past? Will drinking or drug use make it difficult for you to stay housed or afford your housing? Y N Refused If you’ve ever used marijuana, did you ever try it at age 12 or younger? Y N Refused Have you ever had trouble maintaining your housing, or been kicked out of an apartment, shelter program or other place you were staying, because of: A mental health issue or concern? Y N Refused A past head injury? Y N Refused A learning disability, developmental disability, or other impairment? Y N Refused Do you have any mental health or brain issues that would make it hard for you to live Y N Refused independently because you’d need help? Are there any medications that a doctor said you should be taking that, for whatever Y N Refused reason, you are not taking? Are there any medications like painkillers that you don’t take the way the doctor Y N Refused prescribed or where you sell the medication? Follow-Up Questions On a regular day, where is it easiest to find you and what time of place: day is easiest to do so? time: : or Morning/Afternoon/Evening/Night Is there a phone number and/or email where someone can safely phone: ( ) - get in touch with you or leave you a message? email: Ok, now I’d like to take your picture so that it is easier to find you Yes No Refused and confirm your identity in the future. May I do so?
staying because of your physical health? Do you have any chronic health issues with your liver, kidneys, stomach, lungs or heart? Y N Refused Do you have any physical disabilities that would limit the type of housing you could access, or would make it hard to live independently because you’d need help? Y N Refused When you are sick or not feeling well, do you avoid getting help? Y N Refused Are you currently pregnant, have you ever been pregnant or have you ever gotten someone pregnant? Y N N/A or Refused Has your drinking or drug use led you to being kicked out of an apartment or program where you were staying in the past? Y N Refused Will drinking or drug use make it difficult for you to stay housed or afford your housing? Y N Refused If you’ve ever used marijuana, did you ever try it at age 12 or younger? Y N Refused Have you ever had trouble maintaining your housing, or been kicked out of an apartment, shelter program or other place you were staying, because of: A mental health issue or concern? Y N Refused A past head injury? Y N Refused A learning disability, developmental disability, or other impairment? Y N Refused Do you have any mental health or brain issues that would make it hard for you to live independently because you’d need help? Y N Refused Are there any medications that a doctor said you should be taking that, for whatever reason, you are not taking? Y N Refused Are there any medications like painkillers that you don’t take the way the doctor prescribed or where you sell the medication? Y N Refused Follow-Up Questions On a regular day, where is it easiest to find you and what time of day is easiest to do so? place: time: : or Morning/Afternoon/Evening/Night Is there a phone number and/or email where someone can safely get in touch with you or leave you a message? phone: ( ) - email: Ok, now I’d like to take your picture so that it is easier to find you and confirm your identity in the future. May I do so? Yes No Refused