Social Determinants of Health Assessment

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SCREENING QUESTIONS

Have you been discharged from the armed forces of the United States? Please skip this question if you are under 18 years old *

What language are you most comfortable speaking? *

How many family members, including yourself, do you currently live with? *

What is your housing situation today? *

Are you worried about losing your housing? *

What is the highest level of school that you have finished? (Please skip this question if you are under 18 years old) *

What is your current work situation? (Please skip this question if you are under 18 years old) *

In the past year, have you or any family members you live with been unable to get any of the following when it was really needed? Check all that apply. *

Food
Utilities
Clothing
Child Care
Medicine or Any Health Care (Medical, Dental, Mental Health, Vision)
Phone
Other
I choose not to answer this question

Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living? Check all that apply. *

Yes, it has kept me from medical appointments or from getting my medications
Yes, it has kept me from getting to non-medical meetings, appointments, work, or from getting things that I need
No
I choose not to answer this question

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) *

Stress is when someone feels tense, nervous, anxious, or can’t sleep at night because their mind is troubled. How stressed are you? *

In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility? *

Are you a refugee? *

In the past year, have you been afraid of your partner or ex-partner? *

Do you feel physically and emotionally safe where you currently live? *

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CONTACT INFORMATION

First Name *

Last Name *

Date of Birth *

Phone Number *

Email *

Medicaid ID *

Social Determinants of Health Assessment

Social Needs Screening Tool