Online Health Screener

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This form can be filled out by anyone who would like to discuss concerns related to their health, get information about health care services in our community, and be assisted to connect to the services that you may require. These forms will be received by the Outreach Coordinator who will forward them to the Assumption Cares Health Screener volunteer as needed.

Full Name *

Phone Number *

Email Address

GENERAL HEALTH

Are you in need of assistance with obtaining a primary doctor or care provider?

Yes

Clear selection

Do you have any health concerns at the present time?

Yes

Clear selection

Do you need support with managing your general health care concerns?

Yes

Clear selection

Would you agree to be referred to a community agency that may be able to help you?

Yes

Clear selection

MEDICATIONS

Are you currently taking medications?

Yes

Clear selection

If you are taking any medication and do not understand why you are taking one or more of those medications, would you like support with managing and understanding your medications?

Yes

Clear selection

If you answered YES to any of the previous questions, would you agree to have an Assumption Cares Health Screening volunteer contact you?

Yes

Clear selection

Thank you for taking the time to filling out our Health Screener! The responses to this form are checked every Monday. Please allow time for the Volunteer Health Screener to contact you. You will be contact within one week.

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