Do you have trouble paying for medicines?
Yes/ No
In the last 12 months, have you needed to see a doctor, but could not because of cost?
Yes/No
In the past year have you or any family members you live with been unable to get any of the following when it was really needed?
Medicine or any health care (Medical, Dental, Mental Health, Vision): Yes/No
What is your main insurance?
None/uninsured
Medicaid
CHIP Medicaid
Medicare
Other public insurance (non CHIP)
Other Public insurance (CHIP)
Private insurance
In the past 3 months, did you have trouble paying for any of the following? (Select ALL that apply)
Medical needs
Optional: How hard is it for you to get your medications and medical supplies when you need them?
Not at all hard
Somewhat hard
Very hard
University of San Francisco California