Social Screening
Patient Name
*
First Name
Last Name
Patient Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Housing
What is your housing situation today?
*
I do not have housing. (I am staying with others, in a hotel, in a shelter, living on the street, car, abandoned building, park, etc.
I have housing today, but I am worried about losing housing in the future.
I have housing.
Think about the place where you live. Do you have problems with any of the following? (check all that apply)
*
Bug infestation
Mold
Lead paint or pipes
Inadequate heat
Oven or stove not working
No or not working smoke detectors
Water leaks
None of the above
Food
Within the past 12 months, you have worried that your food would run out before you got money to buy more?
*
Often true
Sometimes true
Never
Within the past 12 months, the food you bought just didn't last and you didn't have money to get more.
*
Often true
Sometimes true
Never
Transportation
In the past 12 months, 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 getting medications.
Yes, it has kept me from non-medical meetings, appointments, work or getting things that I need.
No
Utilities
In the past 12 months, has the electric, gas, or water company threatened to shut off services in your home?
*
Yes
No
Actively shut off/ shut off at least once
Personal Safety
How often does anyone, including family...
*
Never
Rarely
Sometimes
Fairly often
Frequently
...physically hurt you?
...insult or talk down to you?
...threaten you with harm?
...scream or curse at you?
Assistance
Would you like help with any of these needs?
*
Yes
No
Submit
Should be Empty: