This image shows page 3 of the Accountable Health Communities Health-Related Social Needs Screening Tool.
Page 3 of the Accountable Health Communities Health-Related Social Needs Screening Tool shows 3 questions about social needs. A patient’s answers may indicate unmet health-related social needs.
Under Living Situation, question 1 asks:
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)
Question 2 asks:
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
Under the Food heading, question 3 asks:
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 in the last 12 months.
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
