AHC Health Related Social Needs Screening Questions
Consent
We use this survey to understand needs our members have which could interfere with good health. We may share your answers with your other healthcare providers, and with your health plan and social services organizations, so they can determine if you qualify for any free non-medical services that could be helpful. Please check this box if you agree to continue. You can choose not to answer this survey, but we can only check for services if you do answer
Consent Options
Member Consents
Member does not consent.
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
Date
Medicade CIN #
Housing/Utilities
1. 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 outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park)
2. Think about the place you live. Do you have problems with any of the following? 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
3. In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home?
Yes
No
Already shut off
Food Security
4. Within the past 12 months, you worried that your food would run out before you got money to buy more.
Often true
Sometimes true
Never true
5. 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 true
Transportation
6. 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
Employment
7. Do you want help finding or keeping work or a job?
Yes, help finding work
Yes, help keeping work
I do not need or want help
Back
Next
Education
8. Do you want help with school or training? For example, starting or completing job training or getting a high school diploma, GED or equivalent.
Yes
No
Interpersonal Safety
Because violence and abuse happen to a lot of people and affects their health we are asking the following questions.
A score of 11 or more when the numerical values for answers to [the four questions] are added shows that the person might not be safe
9. How often does anyone, including family and friends, physically hurt you?
Never (1)
Rarely (2)
Sometimes (3)
Fairly often (4)
Frequently (5)
10. How often does anyone, including family and friends, insult or talk down to you?
Never (1)
Rarely (2)
Sometimes (3)
Fairly often (4)
Frequently (5)
11. How often does anyone, including family and friends, threaten you with harm?
Never (1)
Rarely (2)
Sometimes (3)
Fairly often (4)
Frequently (5)
12. How often does anyone, including family and friends, scream or curse at you?
Never (1)
Rarely (2)
Sometimes (3)
Fairly often (4)
Frequently (5)
Physical Ability
13. Do you have serious difficulty walking or Climbing stairs? (5 years or older)
Yes
No
Asked but member declined to answer
Screener did not ask member
14. Do you have difficulty dressing or bathing? (5 years or older)
Yes
No
Asked but member declined to answer
Screener did not ask member
Preview PDF
Submit
Should be Empty: