| 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.