Appendix A
APPENDIX A – Your Current Life Situation Kaiser Permanente
19-Item Your Current Life Situation
Kaiser Permanente adapted YCLS v.2.0 (shorter form) (11-10-2016)
- Which of the following best describes your current living situation (Select One Only)
☐ Live alone in my own home (house, apartment, condo, trailer, etc.); may have a pet
☐ Live in a household with other people
☐ Temporarily staying in a shelter or homeless
☐ Other
- Do you have any concerns about your current living situation, like housing conditions, safety, and costs?
☐ Yes ☐ Condition of Housing ☐ Lack of more permanent housing
☐ Ability to pay for housing or utilities ☐ Feeling safe ☐ Other
☐ No
- In the past 3 months, did you have trouble paying for any of the following? (Select ALL that apply)
☐ Food ☐ Housing ☐ Heat and Electricity ☐ Medical Needs ☐ Transportation
☐ Childcare ☐ Debts ☐ Other ☐ None of these
- In the past 3 months, how often have you worried that your food would run out before you had money to buy more?
☐ Never ☐ Sometimes ☐ Often ☐ Very often
- Has lack of transportation kept you from medical appointments or from doing things needed for daily living? (Select ALL that apply)
☐ Kept me from medical appointments or from getting medications
☐ Kept me from doing things needed for daily living
☐ Not a problem for me
- In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?
☐ Never ☐ Almost Never ☐ Sometimes ☐ Fairly Often ☐ Very often
- Are you easily able to get enough healthy food to eat? ☐ Yes ☐ No
- Are you a primary caregiver for a child under the age of 18 or for someone who is frail, chronically ill, or has a physical or mental disability? (Select ALL that apply)
☐ Yes ☐ 1+ Child(ren) ☐ Yes, someone who is frail, ill, or has a disability ☐ No
- 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
- Do you have someone you could call if you needed help? ☐ Yes ☐ No
- During the past month, how much stress would you say you have experienced?
☐ A lot of stress ☐ A moderate amount of stress ☐ Relatively little stress ☐ Almost no stress at all
- In the past 12 months, have you been physically or emotionally hurt or felt threatened by a current or former spouse/partner, a caregiver, or someone else you know?
☐ Yes ☐ Current spouse/partner ☐ Former spouse/partner ☐ Caregiver ☐ Someone else
☐ No
- How often do you feel lonely or isolated from those around you?
☐ Never ☐ Rarely ☐ Sometimes ☐ Often ☐ Always
- How often do you see or talk to people that you care about and feel close to? (For example, talking to friends on the phone, visiting friends or family, going to church or club meetings)
☐ Less than once a week ☐ 1-2 days a week ☐ 2-4 days a week ☐ 5 or more days a week
- When did you last have your teeth cleaned and checked by a dentist or hygienist?
☐ Less than 7 months ago ☐ 7-12 months ago ☐ More than a year ago ☐ Never had this done
- How confident are you that you can manage your current medical conditions day-to-day?
☐ Very confident ☐ Somewhat confident ☐ Not confident
- Has a spouse/partner, family member, or friend ever been financially abusive towards you? That is, stolen money from you, not paid back a loan, etc.?
☐ Yes ☐ No
- In general would you say your health is good?
☐ Excellent ☐ Very Good ☐ Good ☐ Fair ☐ Poor
- Do any of your health conditions interfere with your activities?
☐ Yes ☐ No
