Social Determinants of Health Screening
Completed by the primary caregiver for each child/patient
Your Name (primary caregiver)
In the past month, did poor physical or mental health keep you from doing your usual activities, like work, school or a hobby?
*
YES
NO
N/A
In the past year, was there a time when you needed to see a doctor but could not because it cost too much?
*
YES
NO
N/A
Do you ever eat less than you feel you should because there is not enough food?
*
YES
NO
N/A
Do you have a job or other steady source of income?
*
YES
NO
N/A
Are you worried that in the next few months you may not have safe housing that you own, rent or share?
*
YES
NO
N/A
In the past year, have you had a hard time paying your utility company bills?
*
YES
NO
N/A
Do you think completing more education or training, like finishing a GED, going to college, or learning a trade, would be helpful for you?
*
YES
NO
N/A
Do you have a dependable way to get to work or school and your appointments?
*
YES
NO
N/A
Do you have enough household supplies? For example, clothing shoes, blankets, mattresses, diapers, toothpaste and shampoo?
*
YES
NO
N/A
Does getting childcare make it hard for you to work, go to school, or study?
*
YES
NO
N/A
Does getting eldercare make it hard for you to work, go to school, or study?
*
YES
NO
N/A
Do you feel safe in your current home environment or surroundings?
*
YES
NO
N/A
Would you like to receive assistance with any of these needs?
*
YES
NO
N/A
Are any of your needs urgent?
*
YES
NO
N/A
PATIENT Full Name
*
PATIENT Date of Birth
*
/
Month
/
Day
Year
Please verify that you are human
*
Submit
Should be Empty: