LA P.A.T.H.S.
Health Systems Navigation Survey
1612 Fairfield Ave., Shreveport, LA 71101
Phone: 318-227-9010 Email: This e-mail address is being protected from spambots. You need JavaScript enabled to view it
The purpose of this survey is to identify barriers that prevent individuals living with HIV/AIDS from stabilizing in HIV Medical Care. Additionally, the information in this survey will be used to help develop programs and services which will better address the needs of persons living with HIV/AIDS. All information in this survey is kept strictly confidential and will not be shared by LA-PATHS.
*For your participation in this survey you may choose to receive a free $5 gift card.
Name: (optional)
First: _______________________________ Last: _____________________________
Address: _______________________________________________________________
City: _____________________________ State: ____________ Zip: ____________
Phone: (_____) __________________ Gender: Male Female Age: __________
Marital Status: Single Married Separated Divorced Children: Yes No
Which of the following best describes your sexual orientation? heterosexual bisexual homosexual transgendered
Who provides your current primary medical treatment?
Doctor __________________________ Address _______________________________
Phone Number (_____) _______________________
Where do you receive your current dental treatment?
Doctor __________________________ Address _______________________________
Phone Number (____) _______________________
Please list any other medical provider’s ________________________________________________________________________
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When did you last receive medical attention? ________________________________________________________________________
Have you ever been tested for HIV? Yes No (If yes, when & what were the results)
________________________________________________________________________
Are you currently taking medications for the treatment of HIV? Yes No
(If yes please list medications)
________________________________________________________________________________________________________________________________________________
Have you experienced adverse side effects from your medications that prevent you from taking them as prescribed? Yes No (If yes, please explain & have you discussed this with your doctor) ________________________________________________________________________
________________________________________________________________________
How many times would you say that you have missed your prescribed dosage within the last 30 days? Never Occasionally1-2/mo Often-3 or more times /month
How do you normally get your prescriptions filled? ________________________________________________________________________
________________________________________________________________________
Do you currently receive assistance in paying for your medications? Yes (If yes, please explain) No ________________________________________________________________________________________________________________________________________________
Have you used drugs other than those prescribed for medical reasons? Yes No (If yes, please describe)
________________________________________________________________________________________________________________________________________________
Within the last year have you been treated for any substance abuse problems? Yes No (If yes are you currently attending AA, NA, or CA or other support groups; if so when & where) _____________________________________________________________________
Have you ever been assessed for mental health issues? (Such as depression, anxiety, bipolar disorder, schizophrenia, obsessive-compulsive disorder etc?)
Yes No (If yes, please explain)
________________________________________________________________________________________________________________________________________________
How would you rate your overall health?
Excellent Good Fair Poor
What do you feel could be done to improve your overall health? (Please be as specific as possible) ________________________________________________________________________________________________________________________________________________
How would you rate your doctor?
Excellent Good Average Below Average Poor)
Do you feel that your doctor listens or spends enough time with you? Yes No (If no, please explain)
________________________________________________________________________________________________________________________________________________
Are there any concerns you feel are not addressed by your health care provider? Yes No (If yes, please explain)
________________________________________________________________________________________________________________________________________________
Have you incurred problems while attempting to schedule appointments? Yes No
Would it be helpful to receive a reminder a few days before your scheduled appointment? Yes No
How do you normally get to your doctor appointments?
Own Car Public Transportation Someone Takes Me
Does anyone accompany you to your doctor’s appointments? Yes No (If Yes who)
Name: ________________________ Contact Number (_____) ____________________
What is this individual’s relationship to you? _________________________________
How often do you miss your scheduled doctor appointments & Why?
(Never Rarely Occasionally Frequently)
Reason(s) _______________________________________________________________
________________________________________________________________________
Do you have any physical limitations that would prevent you from attending your doctor’s appointments? Yes (If yes, please explain) No ________________________________________________________________________
________________________________________________________________________
Please describe any additional barriers that would prevent you from attending your scheduled appointments.
________________________________________________________________________________________________________________________________________________
If given the opportunity to change to a new provider would you do so? Yes No
(If yes, please explain) ________________________________________________________________________________________________________________________________________________
Which best describes your current living status?
a) Live alone b) Live with spouse c) Live with roommate d) Live with parents
e) Transitional housing
How is it paid for? _______________________________________________________
How would you describe your current living environment? Stable Unstable
If unstable, what do you feel could be done to help you achieve greater stability?
________________________________________________________________________
How would you describe your current support system?
(Excellent Okay Nonexistent-I don’t have one)
Do you feel you would benefit by having more personal support? Yes No (If yes please describe)
________________________________________________________________________
Do you feel you would benefit from greater spiritual support? Yes No
(If yes please describe)
________________________________________________________________________
Would you be open to attending periodic support group meetings? Yes No
________________________________________________________________________
Describe any additional services you may benefit from (please describe in detail) ________________________________________________________________________________________________________________________________________________
Comments Section:
Please share any additional concerns that you feel will help us to better meet your health care needs.
________________________________________________________________________
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Would you like to receive periodic email information from LA PATHS concerning upcoming events, if so please list your email address: Email Address: ____________________________________
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<!--[endif]--> No I do not wish to receive the free gift card.
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<!--[endif]--> Yes I would like to receive the free gift card.
Address gift card is to be mailed to (If different from address listed on form)
Mailing address: _________________________________________________________
City____________________________ State: ____________ Zip: ____________
* Survey must be completed in full in order to receive the free gift card. Please allow 7-10 business days for receipt of your gift card.
