Support Needs Assessment
Your responses to this assessment will be confidential and used to determine how KFAC can assist you. 
Sign in to Google to save your progress. Learn more
Are you or anyone in your home living with a chronic disease? 
 *
Check all that apply
Required
Which chronic disease(s) are you or your household member living with?  *
Check all that apply
Required
How long have you been diagnosed? *
Do you see a specialist doctor? *
Check all that apply
How often do you visit a medical doctor about your condition? *
Do you take medication? *
Do you have health and dental insurance? *
Would you like more information or assistance with any of the below areas? *
Check all that apply
Required
Do you have access to healthy foods?  *
Do you have reliable transportation? *
How often do you/your family eat fast food in a week? *
What type of specific assistance or information are you seeking?  *
Please be detailed as possible
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms