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Social Determinants of Health Assessment

Social Needs Screening Tool

Please complete the following survey. Jai Medical Systems will use your responses to connect you with resources which may be able to assist you. The responses you provide to this survey will not be distributed without your consent.

Questions 1-10 are reprinted with permission from the National Academy of Sciences, courtesy of the National Academies Press, Washington, D.C.

This is adapted from a tool published by the American Academy of Family Practitioners in accordance with their license for the purpose of promoting health equity.

*Billioux A, Verlander K, Anthony S, and Alley D. National Academy of Medicine. Standardized screening for health-related social
needs in clinical settings: the accountable health communities screening tool. National Academies Press. Washington, D.C. https://nam.edu/wp-content/uploads/2017/05/StandardizedScreening-for-Health-Related-Social-Needs-in-Clinical-Settings.pdf. Accessed November 14, 2017.