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Barrier Assessment Checklist
Patient Mobile Number:
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Please check all barriers that the patient is having:
FINANCIAL AND INSURANCE
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Difficulty meeting copays
Financial planning
Low financial literacy
Non‐medical financial needs
Uninsured
Underinsured
Other
You chose "Other", please specify
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LOGISTICAL
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Clothing
Dependent Care
Food
Housing
Transportation
Utilities
Other
You chose "Other", please specify
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CARE COORDINATION
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Appointment making
Home health care
Incorrect referrals or orders
Needs referral
Next stage of care
Physical comorbidity
Rx or medical supplies
Other
You chose "Other", please specify
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CULTURAL, SPIRITUAL AND DISTRESS
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Beliefs conflict with treatment
Difficulty coping with diagnosis
Difficulty coping with treatment
Difficulty coping with survivorship
End of life concerns
Lack of support
Negative perceptions of medical team/care
Mental health comorbidity
Spiritual crisis
Stigma/discrimination
Treatment related depression or anxiety
Other
You chose "Other", please specify
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EMPLOYMENT
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Ability to work through treatment
Family member’s employment
Needs job accommodations
Stigma/discrimination
Unemployed
Other
You chose "Other", please specify
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COMMUNICATION
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Cultural barriers to communication
Health literacy
Language barrier
Literacy
Other
You chose "Other", please specify
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