Social Determine of Health Questionaire
Social Determinant of Health (SDOH) Questionnaire
Name
*
Date of Birth
-
Month
-
Day
Year
Email Address
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
1. In the past year, have you or any family members you live with been unable to get any of the following when it was really needed? Check all that apply.
Food or Utilities
Phone
Clothing
Housing
Childcare
I choose not to answer this question
Medicne or any health care resource (medical, dental,mental health, vision)
Other
2. Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?
Yes
No
3. Were you ever unable to afford a healthcare visit’s copayment?
Yes
No
4. Have you struggled with finding or keeping work or a job?
Yes
No
5. Please choose which most accurately describes your feelings on your current living conditions:
Satisfied
Unsatisfied
6. How often does this describe you? I don't have enough money to pay my bills:
Never
Rarely
Sometime
Often
Always
Patient Signature
Date
-
Month
-
Day
Year
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