1. In the past 2 months, did you or others you live with eat smaller meals or skip meals because you didn't have money for food? _____ Yes _____ No 2. Are you homeless or worried that you might be in the future? _____ Yes _____ No 3. Do you have trouble paying for your utilities (gas, electricity, phone)? _____ Yes _____ No 4. Do you have trouble finding or paying for a ride? _____ Yes _____ No 5. Do you need daycare, or better daycare, for your kids? _____ Yes _____ No 6. Are you unemployed or without regular income? _____ Yes _____ No 7. Do you need help finding a better job? _____ Yes _____ No 8. Do you need help getting more education? _____ Yes _____ No 9. Are you concerned about someone in your home using drugs or alcohol? _____ Yes _____ No 10. Do you feel unsafe in your daily life? _____ Yes _____ No 11. Is anyone in your home threatening or abusing you? _____ Yes _____ No
• The WellRx Toolkit was developed by Janet Page-Reeves, PhD, and Molly Bleecker, MA, at the Office for Community Health at the University of New Mexico in Albuquerque. Copyright © 2014 University of New Mexico.