Social Determinants of Health

Date*

County*

Patient Name*

First NameLast Name

DOB*

Social Déterminants of Health – Patient Screening Questionnaire

This form is to help assist our providers to determine what form of assistance and what type of resources our office can assist you and your family with, to ensure that you are meeting your basic needs and maintaining a quality of life. Please complete the form below. Our office will follow up with you. Thank you!

HealthCare

In the past month, did poor physical or mental health keep your family from doing their usual activities like work, school, or hobby?*

NoYesN/A

In the past year, was there a time when a family member needed to see a doctor but could not because it cost too much?*

NoYesN/A

Food

Does your family ever eat less than you feel they should because there is not enough food?*

NoYesN/A

Employment & Income

Do the parents/guardians have a job or other steady source of income?*

NoYesN/A

Housing & Shelter

Are you worried that in the next few months your family may not have safe housing that you own, rent, share?*

NoYesN/A

Utilities

In the past year, has your family had a hard time paying the utility company bills?*

NoYesN/A

Child Care

Does your family struggle with getting childcare?*

NoYesN/A

Education

Do you think completing more education or training, like finishing a GED, going to college, or learning a trade, would be helpful for your family?*

NoYesN/A

Transportation

Does your family have a dependable way to get to work or school, and your appointments?*

NoYesN/A

Clothing & Household

Does your family have enough household supplies? (For example – clothing, shoes, blankets, mattress, diapers, toothpaste, shampoo.)*

NoYesN/A

General

Would your family like to receive assistance with any of these needs?*

NoYesN/A

Any of your needs URGENT?*

NoYesN/A

Abuse

Does anyone in your family feel unsafe or scared at home or anyone physically or mentally causing harm?*

NoYesN/A