Social Screening
Required for Patients 18+
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
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25
26
27
28
29
30
31
Day
Please select a year
2026
2025
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
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1971
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1969
1968
1967
1966
1965
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1963
1962
1961
1960
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1958
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1956
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1954
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1952
1951
1950
1949
1948
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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
In the past 2 months, do you or others you live with eat smaller meals or skip meals because you do not have money for food?
Yes
No
Are you homeless or worried that you might be in the future?
Yes
No
Do you have trouble paying for your utilities (gas, electricity, water)?
Yes
No
Do you have trouble finding or paying for a ride?
Yes
No
Do you need daycare or better daycare, for your kids?
Yes
No
Are you unemployed or without regular income?
Yes
No
Do you need help finding a better job?
Yes
No
Do you need help getting more education?
Yes
No
Are you concerned about someone in your home using drugs or alcohol?
Yes
No
Do you feel unsafe in your daily life?
Yes
No
Is anyone in your home threatening or abusing you?
Yes
No
Submit
Should be Empty: