Social Needs Screening

Social Needs Screening
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Parent Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Language
Best days/times to call

Please answer the questions below:*

Rows	Yes	No
In the last 12 months, did you ever eat less than you felt you should because there wasn’t enough money for food?
In the last 12 months, has the electric, gas, oil, or water company threatened to shut off your services in your home?
Are you worried that in the next 2 months, you may not have stable housing?
Do problems getting child care make it difficult for you to work or study?
In the last 12 months, have you needed to see a doctor, but could not because of cost?
In the last 12 months, have you ever had to go without health care because you didn’t have a way to get there?
Do you ever need help reading hospital materials?
I often feel that I lack companionship.
Are any of your needs urgent? For example: I don’t have food tonight, I don’t have a place to sleep tonight.
If you checked YES to any boxes above, would you like to receive assistance with any of these needs?

Should be Empty: