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  •  Food insecurity
  •  Housing Insecurity
  •  Transportation Insecurity
  •  Childcare insecurity
  •  Phone insecurity
  •  Utilities insecurity
  •  Healthcare Access insecurity
  •  Veteran Status
  •  Farmworker Status
  •  Material Security
  •  Refugee Status
  •  Physical Safety
  •  Domestic Violence
  •   
  •  Income / Poverty
  •  Insurance Status
  •   
  •  Education
  •  Employment
  •  Social Isolation
  •  Stress
  •  Incarceration History
  •   
  •  Sexually Active
  •   
  •  Pregnancy Episode
  •   
  •  STOP HERE
  •   
  •  Encounter Type: Telehealth - *For comment in "encounter type" submission
  •  Neighborhood?
  •  English Proficiency
  •  Literacy
  •