Screening Questionnaire

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Check Your Eligibility *

Are you a patient of Harmony Healthcare Long Island (HHLI)?

Yes

No

Have you been diagnosed with any of the following? (check all that apply) *

Diabetes

Heart Disease

Prediabetes

High Cholesterol

High Blood Pressure

Obesity

None of the Above

Are you enrolled in SNAP? *

Yes

No

Are you enrolled in WIC? *

Yes

No

Are you enrolled in Medicaid? *

Yes

No

For this program, we need to ask you a few questions about the food eaten in your household in the last 30 days and whether you were able to afford the food you need. Please answer "yes" if you felt this way one time, some of the time, or all of the time. Answer "no" if you never felt this way in the last 30 days. *

In the last 30 days, we worried whether our food would run out before we got money to buy more.

Yes

No

Don't Know / Prefer Not to Answer

In the last 30 days, the food we bought just did not last and we did not have money to get more. *

Yes

No

Don't Know / Prefer Not to Answer