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Book Appointment
Screening
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
–
Step
1
of 3
Name
*
What is your age?
*
In the past 12 months, have you:
Worried about running out of food before getting money to buy more
*
Yes
No
Ran out of food and did not have money to buy more
*
Yes
No
Used a food bank
*
Yes
No
Income
How many people are in your household (as in your tax filing)?
What is your yearly household income?
Transportation
In the past 30 days, how often do you skip going somewhere because of a problem with transportation?
Often
Sometimes
Never
Colorectal Cancer Screening
Type of most recent screening
Colonoscopy
Cologuard
FIT/iFOB Stool test
Are you Assigned Female at Birth? (AFAB)
*
Yes
Yes
No
Will not disclose
Date of Last Pap Smear (Year)
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Result of last Pap Smear
*
Normal
Abnormal
I have never had a Pap Smear
Date of last Mammogram
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Result of last Mammogram
Normal
Abnormal
I have not had a Mammogram previously
Next
Over the last 2 weeks, how often have you been bothered by any of the following problems:
PHQ-9
1. Little interest or pleasure in doing things
Not at all
Several days
More than half the days
Nearly every day
2. Feeling down, depressed, or hopeless
Not at all
Several days
More than half the days
Nearly every day
3. Trouble falling or staying asleep, or sleeping too much
Not at all
Several days
More than half the days
Nearly every day
4. Feeling tired or having little energy
Not at all
Several days
More than half the days
Nearly every day
5. Poor Appetite or overeating
Not at all
Several days
More than half the days
Nearly every day
6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down
Not at all
Several days
More than half the days
Nearly every day
7. Trouble concentrating on things, such as reading the newspaper or watching television
Not at all
Several days
More than half the days
Nearly every day
8. Moving or speaking so slowly that others could have noticed, or being so fidgety or restless that you have been moving around a lot more than usual
Not at all
Several days
More than half the days
Nearly every day
9. Thought that you would be better off dead, or of hurting yourself in some way
Not at all
Several days
More than half the days
Nearly every day
If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
Next
Over the last 2 weeks, how often have you been bothered by any of the following problems?
GAD-7
1. Feeling nervous, anxious, or on edge
Not at all
Several Days
Over half the days
Nearly every day
2. Not being able to stop or control worrying
Not at all
Several days
Over half the days
Nearly every day
3. Worrying too much about different things
Not at all
Several days
Over half the days
Nearly every day
4. Trouble relaxing
Not at all
Several days
Over half the days
Nearly every day
5. Being so restless that it's hard to sit still
Not at all
Several days
Over half the days
Nearly every day
6. Becoming easily annoyed or irritable
Not at all
Several days
Over half the days
Nearly every day
7. Feeling afraid as if something awful might happen
Not at all
Several days
Over half the days
Nearly every day
If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with people?
Not difficult
Somewhat difficult
Very difficult
Extremely difficult
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