For each of the following statements

-for *CURRENT* (=last 4 weeks) circle *YES*, *NO*, or *UNKNOWN*

Client states he/she is in good physical health?

Client has access to needed medical services?

      -This question asks if the client has the means to get medical services or whether they have medical insurance.

 Client receives needed medical Services?

      -This question asks whether the client actually go to see his/her doctor.

 Client has a primary care physician?

 Client uses a primary care physician?

 Client has access to needed dental services?

      -This question asks if the client has the means to get dental services or whether they have dental insurance.

 Client receives needed dental services?

      -This question asks whether the client actually go to see his/her dentist.

Is client obese (based on BMI)?

Has client ever been told by a physician that he/she has diabetes?

      -Record Type I or type II only, not gestational diabetes.

Circle *YES*, *NO*, or *UNKNOWN* for the following two statements:

Did client receive physical health services from a DHS clinic or hospital in the past 12 months?

Department of Health Services (DHS) has published a list of their clinics if you're not sure...Harbor/UCLA is an example of a DHS (or County) Hospital).

List of DHS clinics

Does the client have a chronic physical health care problem or problems that require periodic medical services?

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