Health Self-Assessment
Health Self-Assessment
This health self-assessment is designed for you to think about and assess your health or lifestyle habits, goals, and needs outside of a medical setting so that ILRC may support you and offer additional resources or services as appropriate. It is completely voluntary, and you are not required to answer all the questions. You may fill it out and return it to our Community Health Workers (CHWs), or you may fill it out and keep it as a tool for you to identify areas that you would like to request additional resources or services. A paper version and alternate formats are available upon request.
About CHWs
CHWs are here to support you in your health goals. They can provide a variety of services including, guidance and assistance to reach your health goals, health education and awareness, information referral to health services, information on diagnostic health screenings, support with immunizations, locate community resources, and assist with applications for assistance programs like Medicaid and SNAP.
Questions?
If you have any questions for us or would like to talk through the survey with a CHW, please feel free to call 505-266-5022 ext. 2293 or email gsmith@ilrcnm.org. If requested, a CHW will follow up with you via phone or email after you have completed the assessment to continue the conversation.
ABQ Contact
Albuquerque Office: GuruAmrit Smith, Lead Community Health Worker & Special Projects Coordinator, Work Cell: 505-633-8140 / Office: 505-266-5022 ext. 2293, email: gsmith@ilrcnm.org
Socorro Contact
Socorro Office: Caitlin Moore, Community Health Worker, Work Cell: 575-518-4120, cmoore@ilrcnm.org OR Katie Romero, Community Health Worker Work Cell: 575-518-4505, email: kromero@ilrcnm.org
Your Contact Information
This section is OPTIONAL. Please provide your contact information ONLY if you would like a Community Health Worker to follow up with you. All contact information will be kept confidential. Any information you provide will be used anonymously to understand the overall health and wellness of our community.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
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In general, how would you describe your overall health?
Excellent
Good
Average
Poor
How often do you get a health checkup? A checkup is a visit to a doctor’s office with a primary care provider that is NOT for a specific problem.
Once every 6 months
Once a year
Only when needed
Never get it done
Other
How long has it been since your last checkup?
Within the last year
Between 1 - 3 years
More than 3 years
If it has been more than 1 year, please provide some information. For example, you do not have health insurance, office visits are too expensive, the clinic is too far away or not accessible, you don’t have transportation, you cannot find a primary care provider, etc.
If you do not have a primary care provider, are you interested in finding primary care services?
YES
NO
Other
Which vaccines, if any, have you received in the current cold and flu season (October – May)? Check all that apply.
Flu / Influenza
COVID-19
RSV (for ages 60+)
Pneumococcal / Pneumonia (for certain high-risk conditions)
Other
Would you like to schedule any vaccine appointments?
YES
NO, but I would like more information about vaccines
No, I am not interested in getting any vaccines right now
Other
In general, how would you describe your dental health? Dental health includes the condition of your mouth and teeth, including false teeth or dentures.
Excellent
Good
Average
Poor
How often do you visit the dentist?
Once every 6 months
Once a year
Only when needed
Never get it done
Other
If it has been more than 1 year since your last dental visit, are you interested in finding dental services or learning more about oral health? (check all that apply)
YES, I am interested in finding dental services
YES, I am interested in learning more about oral health
NO, I am not interested in finding dental services or learning more about oral health
In general, how would you describe your eye health? Eye or vision health includes the condition of your eyes, vision, eye diseases, etc.
Excellent
Good
Average
Poor
How often do you visit the eye doctor?
Once every 6 months
Once a year
Only when needed
Never get it done
Other
If it has been more than 1-2 years since the last time you’ve visited the eye doctor, you’ve recently been diagnosed with diabetes, or if you have had a recent change to your vision, are you interested in finding vision services or learning more about vision health? (select all that apply)
YES, I am interested in finding vision services
Yes, I am interested in learning more about vision health
NO, I am not interested in finding vision services or learning more about vision health
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Do you currently see any specialists? A specialist is a physician that specializes in one kind of medical care. A Cardiologist is an example of a specialist.
YES
NO
If “yes,” what are you seeing the specialist for?
Do you have any chronic conditions? Chronic conditions are conditions that last one year or more and require ongoing medical attention, or limit activities of daily living, or both. Major chronic conditions include heart disease and stroke, cancer, diabetes, asthma, high blood pressure, high cholesterol, and chronic lung or kidney disease.
YES
NO
If "yes," please describe:
Would you be interested in learning more about chronic conditions, risk factors, prevention, or management?
YES
NO
Do you ever have trouble taking medicines the way you have been told to take them?
I do not have to any medicines
I always take them as prescribed
Sometimes I take them as prescribed
I seldom take them as prescribed
Other
If you do have trouble taking medicines the way you have been told to take them, can you provide some information. For example, are they too expensive, is it hard to get the medicine because of transportation or shipping costs, are the instructions confusing, do they make you feel bad, do you need more information about the medicine, etc.?
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Feeling down or having the blues now and then is normal
Everyone feels anxious from time to time — it's a normal response to stressful situations. If you are having severe or ongoing feelings of depression and anxiety, or if you’ve had two or more weeks with changes to your thoughts, moods, or body that make it hard to manage work, school, home, or relationships, it may be time to ask for help. Everyone needs help sometimes. If you or someone you know is struggling or in crisis, help is available. Call or text 988 or chat 988lifeline.org. You’ll be able to speak with a trained crisis counselor any time of day or night. https://www.samhsa.gov/find-support/how-to-cope/signs-of-needing-help
Over the past month, have you felt tense, anxious, or depressed?
Almost every day
Sometimes
Rarely
Never
Do you have a current behavioral or mental health therapist or provider?
YES
NO
If YES, when was your last visit?
If NO, are you interested in learning more about behavioral or mental health therapy and / or finding a provider?
YES
NO
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In the last 7 days, how often did you eat 3 or more servings of fruits or vegetables in a day? Each time you ate a fruit or vegetable counts as one serving. It can be fresh, frozen, canned, cooked or mixed with other foods.
Every day
3 - 6 days
1 - 2 days
0 days
In general, how would you rate your access to fresh, healthy food and regular hot meals?
Excellent
Good
Average
Poor
Are you interested in learning more about resources for food, including cooking classes, prepared meals, and groceries?
YES
NO
In a typical week, how much alcohol do you drink? 1 drink is 1 beer, 1 glass of wine, or 1 shot of distilled spirits.
None
1 drink per day or less
2 drinks per day
More than 2 drinks per day
Other
In the past month have you smoked, used tobacco, or other nicotine products?
YES
NO
If YES, do you want to quit smoking, using tobacco or other nicotine products?
YES
I am working on quitting or cutting back right now
NO
Not applicable
In the past 7 days, how often did you exercise for at least 20 minutes in a day? Exercise includes walking, housekeeping, jogging, weights, a sport or playing with children. It can be done on the job, around the house, just for fun, or as a work-out.
Every day
3 - 6 days
1 - 2 days
0 days
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Are there any areas in your life that you are interested in addressing or discussing?
Home life (where you live or who you live with)
Diet
Exercise
General health
Behavioral, mental, or emotional health
Social connections (friends, family, activities, etc.)
Drinking alcohol
Smoking
None
Other
Small everyday changes can have a big impact on your health. Are there any changes you are interested in making over time? Check any that apply.
Exercise regularly, eat better, and/or lose weight
Cut back or quit drinking alcohol
Cut back or quit smoking, using tobacco, or nicotine products
Seek treatment for drug or substance abuse
Get a flu / COVID-19 / RSV / Shingles vaccine
Get tested for high blood pressure, high cholesterol and diabetes OR if I already have any of them, visit a healthcare provider for check-ups for these conditions, etc.
Committing to keeping up all of the healthy things I do now
Other
Would you be interested in joining a support group? Support groups can be beneficial for mental health by providing a shared experience, a sense of belonging, and a safe place for discussion. They are generally peer-led rather than clinician-led, and generally are not a substitute for individual therapy with a clinician.
YES
NO
If YES, what type of support group would you be interested in joining? Some examples of groups could be a cross disability support group, a diabetes support group, an exercise group, cooking class, long COVID, or any areas you are interested in connecting with other people who have similar interests or experiences.
Do you have any questions, or is there anything else you would like to discuss with a Community Health Worker?
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