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Allapattah Health Fair Preregistration

Page 1 of 3

Hello!

The University of Miami Department of Community Service (DOCS) will be having a health fair in Allapattah on Saturday, April 15th at the Village of Allapattah YMCA Family Center. Anyone can come and receive free health screenings of blood pressure, blood sugar, cholesterol, bone density, and more. A doctor will speak to you about your results and can help you seek further care if needed. Everyone is welcome regardless of your insurance status, immigration status, or gender.

This is a pre-registration survey. Below, we will ask you some questions which will help us know which health screenings you need to receive. By answering these questions today, you will save time on the day of the fair. In this survey, you can also choose the time slot at which you would like to come to the fair. Walk-ins will also be accepted on the day of the fair, however appointments are highly encouraged so we may practice proper social distancing.

This survey will take approximately 5 minutes. There are 3 pages. You can go back and forth between pages. If you leave the survey after having started it, you will have to start over again. When you finish, you will see a confirmation.

This survey is secure and confidential. The information will only be seen by necessary DOCS volunteers who work at the fair.

Sincerely,

University of Miami Department of Community Service (DOCS)

For urgent questions, please contact (714) 312-4150 or email AHFteam23@gmail.com

Si tiene preguntas urgentes, comuníquese al (714) 312-4150 o email AHFteam23@gmail.com

Allapattah Health Fair

Address: Village of Allapattah YMCA Family Center

2370 NW 17th Ave Miami FL 33142

Date: Saturday, April 15th 2023

Time: 8-2pm

Feria de salud de Allapattah

Dirección: Village of Allapattah YMCA Family Center

2370 NW 17th Ave Miami FL 33142

Fecha: sábado, 15 de abril de 2023

Hora: 8-2pm

Languages

WARNING- DO NOT EDIT THE LANGUAGES FIELD ABOVE UNLESS YOU'VE READ THE DOCUMENTATION FOR THE MULTILINGUAL DATA DICTIONARY. IT WILL BREAK THE ENTIRE REDCAP FORM IF IT IS EDITED INCORRECTLY.

Registration Check-in Time

* must provide value

M-D-Y H:M

First Name

* must provide value

Last name

* must provide value

Is this your first time visiting a DOCS Health Fair?

* must provide value

Yes

reset

Today's Date

* must provide value

M-D-Y

Date of Birth

* must provide value

M-D-Y

Age

View equation

Biological Sex at Birth

* must provide value

Male

Female

reset

SKIP Check if this person identifies as a different gender.

SKIP Please specify your preferred gender:

We will contact you before the fair at your phone number as a reminder of your appointment.

Phone Number

* must provide value

Are you currently without a home/homeless?

* must provide value

Yes

reset

Are you currently residing in a shelter?

* must provide value

Yes

reset

PLEASE COLLECT AN EMAIL ADDRESS, PHONE NUMBER AND/OR MAILING ADDRESS THAT THE PATIENT HAS ACCESS TO FOR APPROPRAITE FOLLOW-UP TO OCCUR

MUST PROVIDE VALUE

Address
Depending on which stations you visit, we may mail you the results after the fair.
Put N/A if homeless

Street

* must provide value

Apartment

City

* must provide value

State

* must provide value

Zip Code

* must provide value

Country of Origin

* must provide value

Country of Origin

* must provide value

Which one of the following would you say is your race/ethnicity?

* must provide value

White (Non-Hispanic)

White (Hispanic)

Black (African American)

Black (Caribbean/Haitian)

Black (Hispanic)

Asian/Pacific Islander

Native American

Other

Prefer not to answer

reset

Race (Other)

* must provide value

Language

* must provide value

Other

How did you hear about the health fair this year?

* must provide value

Radio

Mail

Community Flyer

Flyer from school

Social Media

Former Patient

Religious Institution

Word of Mouth

Other

This Question should be Please specify the details of the form of advertisement.

For example if social media, specify whatsapp, facebook, instagram, etc. If radio, specify radio station like 101.5 Lite FM. If school, specify school name like Coral Gables High School, etc.

Avoid using commas in this question.

Other-How did you hear about the fair?

* must provide value

SKIP-Years of Formal Education (may prefer not to answer if uncomfortable)

* must provide value

High school/GED

Vocational training

Associates degree/some years in university

Graduated from university (Bachelor's degree)

Master's degree

Doctorate degree

No response

reset

SKIP-Civil Status (may prefer not to answer if uncomfortable)

Single

Married

Widower

Divorced

Separated

No response

reset

SKIP-Income (may prefer not to answer if uncomfortable)

Less than $5,000

$5,000 to $19,999

$20,000 to $29,999

$30,000 to $49,999

$50,000 to $69,999

$70,000 or more

I don't know

No response

reset

Visit Time- Due to COVID, we now request patients to visit in a certain time slot.

(One selection allowed per column)

First Choice

Second Choice

Third Choice

8-11 AM

reset

11 AM- 2 PM

reset

2 PM - 4 PM

reset

When would you like to come to the fair?

This is the last question on this page. Make sure everything with red text is filled out, otherwise there will be an error message not letting you go forward. The skipped questions will be shown when clicked.

Label

Positive pregnancy/needs prenatal care

Breast mass felt on exam

High suspicion for infection

Any other abnormality on pelvic exam (abnormal bleeding, etc)

Label

Trichomonas

Candida

Bacterial Vaginosis

Other

Label

Sudden, recent hearing loss

Active ear infection/blood/drainage

Active ear pain

Active bouts of vertigo

Hearing asymmetry

Unilateral tinnitus

General hearing loss or dizziness

Any other hearing issues deemed significant by audiologist

Label

Normal Exam

Cataract (left)

Cataract (right)

Cataract (bilateral)

Glaucoma

Optometry

Other

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.

Allapattah Health Fair Preregistration

**PLEASE COLLECT AN EMAIL ADDRESS, PHONE NUMBER AND/OR MAILING ADDRESS THAT THE PATIENT HAS ACCESS TO FOR APPROPRAITE FOLLOW-UP TO OCCUR**

You have selected an option that triggers this survey to end right now.

PLEASE COLLECT AN EMAIL ADDRESS, PHONE NUMBER AND/OR MAILING ADDRESS THAT THE PATIENT HAS ACCESS TO FOR APPROPRAITE FOLLOW-UP TO OCCUR