Accountable Health Communities Core Health-Related Social Screening Questions For questions about housing, food, transportation, and utility needs underlined answer options indicate positive screens for the associated health-related social need. For interpersonal safety, a value greater than 10 when the numerical values for answers to questions 7-10 are summed indicates a positive screen. Housing Instability 1. What is your housing situation today?1,2 I do not have housing (I am 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) I have housing today, but I am worried about losing housing in the future. □ I have housing □ 2. Think about the place you live. Do you have problems with any of the following? (check all that apply)3 Bug infestation □ Mold □ Lead paint or pipes □ Inadequate heat □ Oven or stove not working □ No or not working detectors □ Water leaks □ None of the above □ Food Insecurity 3. Within the past 12 months, you worried that your food would run out before you got money to buy more.4 Often true □ Sometimes true □ Never true □ 4. Within the past 12 months, the food you bought just didn’t last and you didn’t have money to get more.4 Often true □ Sometimes true □ Never true □ Transportation Needs 5. In the past 12 months, has lack of transportation kept you from medical appointments, meetings, work or from getting things needed for daily living? (Check all that apply)1
Accountable Health Communities Core Health-Related Social Screening Questions For questions about housing, food, transportation, and utility needs underlined answer options indicate positive screens for the associated health-related social need. For interpersonal safety, a value greater than 10 when the numerical values for answers to questions 7-10 are summed indicates a positive screen. Housing Instability 1. What is your housing situation today?1,2 □ I do not have housing (I am 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) □ I have housing today, but I am worried about losing housing in the future. □ I have housing 2. Think about the place you live. Do you have problems with any of the following? (check all that apply)3 □ Bug infestation □ Mold □ Lead paint or pipes □ Inadequate heat □ Oven or stove not working □ No or not working detectors □ Water leaks □ None of the above Food Insecurity 3. Within the past 12 months, you worried that your food would run out before you got money to buy more.4 □ Often true □ Sometimes true □ Never true 4. Within the past 12 months, the food you bought just didn’t last and you didn’t have money to get more.4 □ Often true □ Sometimes true □ Never true Transportation Needs 5. In the past 12 months, has lack of transportation kept you from medical appointments, meetings, work or from getting things needed for daily living? (Check all that apply)1
AHC-Screening-Tool.docx