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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
  •  

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