Social Determinants of Health

1
Name* This field is required.
First Name
Last Name
2
UniqueID#* This field is required.
3
What is the patient's email?
4
What is your living situation today?* This field is required.Living Situation
I have a steady place to live
I have a place to live today, but I am worried about losing it in the future
I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park)
5
Think about the place you live. Do you have problems with any of the following?* This field is required.Choose all that apply
Pests such as bugs, ants, or mice
Mold
Lead paint or pipes
Lack of heat
Oven or stove not working
Smoke detectors missing or not working
Water leaks
None of the above
6
Within the past 12 months, you worried that your food would run out before you got money to buy more.* This field is required.Food
Often true
Sometimes true
Never true
7
Within the past 12 months, the food you bought just didn’t last and you didn’t have money to get more.* This field is required.Food
Often true
Sometimes true
Never true
8
In the past 12 months, has lack of transportation kept you from medical appointments, meetings, work or from getting things needed for daily living?* This field is required.Transportation
Yes, it has kept me from medical appointments or getting medications
Yes, it has kept me from non-medical meetings,appointments, work, or getting things that I need
No
9
In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home?* This field is required.Utilities
Yes
No
Already shut off
10
How often does anyone, including family, physically hurt you?* This field is required.Personal safety
Never
Rarely
Sometimes
Fairly often
Frequently
11
How often does anyone, including family, insult or talk down to you?* This field is required.Personal safety
Never
Rarely
Sometimes
Fairly often
Frequently
12
How often does anyone, including family, threaten you with harm?* This field is required.Personal safety
Never
Rarely
Sometimes
Fairly often
Frequently
13
How often does anyone, including family, scream or curse at you?* This field is required.Personal safety
Never
Rarely
Sometimes
Fairly often
Frequently
14
The last 4 Questions have been scored; if the value shown below is greater than 11, the patient is at risk for harm. Please note this in the record.
15
Date
Date
Month
Day
Year
16
SDOH
17
Based upon the results of SDOH, the Patient is at RISK for the following:
Housing Insecurity
Food Insecurity
Inconsistent Transportation
Risk of physical harm
18
Would you like help with any of these needs?* This field is required.
YESNO
19
Today's Provider* This field is required.
Please Select
Please Select
Guy M. Lerner, MD
Leslie Dally, DO
Don Zinno, APRN
Erika Ruth, MD
Craig Rouben, APRN
Tara O'Brien, APRN
Monica Taylor, APRN, PMHNP
Brandi Thomas, APRN, PMHNP
Should be Empty: