Social Determinants of Health
Name
*
First Name
Last Name
Email
example@example.com
Health Plan
*
Aetna
Cigna
Scan
Verda
Wellpoint
Health Plan ID
Age
*
Gender
*
Male
Female
Prefer Not to Answer
Race
*
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Hispanic or Latino or Spanish Origin of Any Race
Primary Language
*
English
Spanish
Vietnamese
Mandarin
Hindi
Other
Do you have a high school degree?
*
Yes
No
Living Situation
What is your living situation today?
*
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 on the street, on a beach, in a car, abandoned building, bus or train station, or in a park).
Do you have any problems with any of the following? (choose all that apply)
*
Pests such as bugs, ants, or mice
Lead Paint or Pipes
Mold
Lack of Heat
Oven or stove that does not work
Smoke detectors missing or not working
Water leaks
Lack of air conditioning
None of the above
Food
Some people have made the following statements about their food situation. Please answer whether the statements were OFTEN, SOMETIMES, OR NEVER true for you and your household within the last 12 months.
Within the past 12 months, you worried your food would run out before you got money to buy more.
*
Often True
Sometimes True
Never True
With in 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 True
TRANSPORTATION
In the past 12 months, has lack of reliable transportation kept you from medical appointments, meetings, work or from getting things needed for daily living?
*
Yes
No
UTILITIES
In the past 12 months has the electric, gas, oil, or water company threatened to shut off services to your home?
*
Yes
No
SAFETY
Because violence and abuse happens to a lot of people and affects their health we are asking the following questions.
How often does anyone, including family and friends, threaten you with harm?
*
Never
Rarely
Sometimes
Fairly Often
Frequently
How often does anyone, including family and friends, scream or curse at you?
*
Never
Rarely
Sometimes
Fairly Often
Frequently
FINANCIAL STRAIN
How hard is it for you to pay for the very basics like food, housing, medical care and heating?
*
Very Hard
Somewhat hard
Not hard at all
EMPLOYMENT
What is your source of income?
*
Wages from a job
Disability
Social Security
Retirement Fund
Prefer not to answer
Do you want help finding or keeping work or a job?
*
I do not need or want help
Yes, help finding work
Yes, help keeping work
FAMILY & COMMUNITY SUPPORT
If for any reason you need help with day-to-day activities such as bathing, preparing meals, shopping, managing finances, etc, do you get the help you need?
*
I don't need any help.
I get all the help I need.
I could use a little more help.
I need a lot more help.
How often do you feel lonely or isolated from those around you?
*
Never
Rarely
Sometimes
Fairly Often
Frequently
SUBSTANCE USE
The next questions relate to your experience with alcohol, cigarettes, and/or other drugs. Some of the substances are prescribed by a doctor (like pain medications), but only count those if you have taken them for reasons or in doses other than prescribed. One question is about illegal drug use, but we only ask in order to identify community services that may be available to help you.
How many times in the past 12 months have you had 4 or more drinks in a day? One drink is 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proofspirits.
*
Never
Once or Twice
Monthly
Weekly
Daily or almost daily
How many times in the past 12 months have you used tobacco products (like cigarettes cigars, snuff, chew, electronic cigarettes)?
*
Never
Once or Twice
Monthly
Weekly
Daily or almost daily
How many times in the past year have you used prescription drugs for non medical reasons?
*
Never
Once or Twice
Monthly
Weekly
Daily or almost daily
How many times in the past year have you used illegal drugs?
*
Never
Once or Twice
Monthly
Weekly
Daily or almost daily
MENTAL HEALTH
Over the last 2 weeks, how often have you been bothered by any of the followingproblems? (If either response triggers a score of 2 or 3, complete a PHQ-9Assessment)
Little interest or pleasure in doing things?
*
Not at all
Several days
More than half of the days
Nearly every day
Feeling down, depressed, or hopeless?
*
Not at all
Several days
More than half of the days
Nearly every day
DISABILITIES
Because of a physical, mental, or emotional condition, do you have difficulty concentrating, remembering, or making decisions?
*
Yes
No
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?
*
Yes
No
FOLLOW-UP
Would you like to speak with someone about concerns you have or need assistance with your healthcare?
*
Yes
No
If yes, what is the best number to contact you?
Please enter a valid phone number.
Submit
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