PRAPARE

PRAPARE

Protocol for responding to and assessing patient assets, risks, and experiences
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Place of Service
If Facility is selected for Location of Service, please identify the name of the Facility.
Personal Characteristics
1. Are you Hispanic or Latino?*

YesNoI choose not to answer this question
2. What race(s) are you? Check all that apply.*

AsianPacific IslanderWhiteNative HawaiianBlack / African AmericanAmerican Indian / Alaskan NativeI choose not to answer this questionOther
3. At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?*

YesNoI choose not to answer this question
4. Have you been discharged from the armed forces of the United States?*

YesNoI choose not to answer this question
5. What language are you most comfortable speaking?*

EnglishLanguage other than English
Name that language are you most comfortable speaking?*
Family and Home
6. How many family members, including yourself, do you currently live with? If you choose not to answer this question type n/a*
7. What is your housing situation today?*

I have housingI do not have housing (stay with others, hotel, shelter, living outside, on the streets, on the beach, in a car, or in a park)I choose not to answer this question
8. Are you worried about losing your housing?*

YesNoI choose not to answer this question
9. What is the address for where you currently live?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Money and Resources
10. What is the highest level of school that you have finished?*

Less than high schoolHigh school diploma or GEDMore than high schoolI choose not to answer this question
11. What is your current work situation?*

UnemployedPart time or temporaryFull timeOtherwise unemployed but not seeking work (student, retired, disabled, unpaid caregiver)I choose not to answer this question
12. What is your primary insurance?*

none/uninsuredMedicaidCHIP MedicaidType option 4MedicarePublic insurance (not CHIP)Other public insurance (CHIP)Private insurance
13 During the past year, what was the total combined income for you and the family members you live with? This information will help us determine if you are eligible for any benefits. If you choose not to answer this question type n/a*

14. In the past year, have you or any family members you live with been unable to get any of the following when it was really needed? Check all that apply.

	Yes	No	No Answer
Food
Utilities
Medicine or any health care (medical, dental , mental health, vision)
Phone
Clothing
Child care

Any other item you or your family has been unable to get when it was really needed that is not already listed above?
15. Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living? Check all that apply.

Yes, it has kept me from medical appointmentsYes, it has kept me from non-medical meetings, appointments, work, or from getting things that I needNoI choose not to answer this question
Social and Emotional Health
16. How often do you see or talk to people that you care about and feel close to? (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)

Less than once a week1 or 2 times a week3 to 5 times a week5 or more times a weekI choose not to answer this question
17. Stress is when someone feels tense, nervous, anxious, or can’t sleep at night because their mind is troubled. How stressed are you?

Not at allA little bitSomewhatQuite a bitVery muchI choose not to answer this question
Optional Additional Questions
18. In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?

YesNoI choose not to answer this
19. Are you a refugee?

YesNoI choose not to answer this
20. Do you feel physically and emotionally safe where you currently live?

YesNoUnsureI choose not to answer this question
21. In the past year, have you been afraid of your partner or ex-partner?

YesNoUnsureI have not had a partner in the last yearI choose not to answer this question
© 2016. National Association of Community Health Centers, Inc., Association of Asian Pacific Community Health Organizations, and Oregon
Primary Care Association. PRAPARE® is proprietary information of NACHC and its partners. All rights reserved. For more information about this
tool, please visit our website at www.nachc.org/PRAPARE® or contact us at prapare@nachc.org.
Should be Empty:

PRAPARE

Personal Characteristics

Family and Home

Money and Resources

Social and Emotional Health

Optional Additional Questions