Social Determinants of Health Screening Tool

Demographics:
Date: ______________
Time: ___________
Name (Last, First, M.I.): _____________________________________________________
Last 4 digits of SS: __________________
Date of Birth: ______________________
Race: _____________________________
Gender (Circle): M / F
1. Primary Language spoken at home: ____________
2. Second Language: ________________
3. Can you read words written in English?
o Yes
o No
4. Can you understand spoken English?
o Yes
o No
5. Can you speak English?
o Yes
o No
6. Patient Identification Confirmed by Assessor:
o By Phone
o Face to Face
6a. If face to face, location of interview____________________________________

Clinical Care:
Access to Care:
7. What is your means of transportation?
o
o
o
o
o

Self
Family/Friend
Public
Medicaid Van
Other _______________________________________________

8. Who is your Primary Care Physician? _________________________________________

9. When you normally receive care, do you go to your Primary Care Physician Office or the
Emergency Room?
o Primary Care Physician Office
o Emergency Room

Care Coordination at Discharge:

10. Have you been in the hospital in the last year?
o Yes
o No
10a. If yes, did the hospital arrange for you to have any of the following services after your
discharge (check all that apply)?
o
o
o
o

Home Health
Medical Equipment
Assistance with prescriptions
An appointment with your Physician

Staff Use Only:

GHS Medical Record #: ___________________
Safety Net Provider Patient ID #: ___________________
2

Access to Prescriptions:
11. Are you able to afford your medications?
o Yes
o No
11a. If no, how do you get your medications?
o
o
o
o
o

Borrow money from friends/family

Prescription Assistance Programs
Hospital Charity
I do not fill some of my medications
I do not fill any of my medications

Quality of Care:
12. Completed annual recommended prevention screenings (see attached)
o Yes
o No

Social and Economic Factors:

Education:
13. Highest Level of Education:
o
o
o
o

Grade School
High School Diploma/GED
Some College
College Graduate

Employment:
14. Are you currently employed?
o Yes
o Full-Time
o Part-Time
o Seasonal
o No
o Disabled
o Retired
3

o Homemaker
o Unemployed, but looking for work
o Never Worked
14a. If you are currently employed, what is your occupation? ___________________
15. Are you a Veteran?
o Yes
o No
Income:
16. What is your source of income (check all that apply)?
o Work
o Social Security
o Retirement
17. What is your monthly income? __________________________
18. What is your annual income? ____________________________
Family and Social Support:
19. Where do you reside?
o
o
o
o

House
Apartment
Mobile Home
Home Shelter

20. Including yourself, how many family members live in your home?
o Adults _______
o Children ______
21. Do you have contact with other family members that do not live with you?
o Yes
o No
22. Are you a single parent?

o Yes
o No
23. Do you attend church?
o Yes
o No
24. Are you involved with support or social groups?
o Yes
o No
24a. If yes, are they:
o Diagnosis related
o Educational
o Social

Health Behaviors:
Smoking:
25. Are you a:
o Current Smoker
o Former Smoker
o Never Smoked
25a. If Current Smoker, how often do you smoke?
o Daily
o Some days, but not every day
25b. If Current Smoker, how many cigarettes a day do you smoke?
o
o
o
o
o

5
6 10
11 20
21 30
>31

25c. If Current Smoker, are you interested in quitting?

o Ready to Quit
o Thinking about Quitting
o Not Ready to Quit
5

Alcohol Use:
26. Did you have a drink containing alcohol in the past year?
o Yes
o No

Alcohol Use Score: _____

Score:
Men- Score 4 is Positive
Women- Score 3 is Positive

26a. If yes, how often did you have a drink containing alcohol in
the past year?
o
o
o
o

Less than monthly (1 point)

Monthly (2 points)
Weekly (3 points)
Daily or almost daily (4 points)

27. If yes, how many drinks did you have on a typical day in the past year?
o
o
o
o
o

1 or 2 (0 points)
3 or 4 (1 point)
5 or 6 (2 points)
7 or 9 (3 points)
10 or more (4 points)

28. If yes, how often did you have 6 or more drinks on one occasion in the past year?
o
o
o
o
o

Never (0 points)
Less than monthly (1 point)
2 or 4 times a month (2 points)
2 or 3 times per week (3 points)
4 or more times per week (4 points)

Diet and Exercise:

29. How many times per week do you exercise?
o
o
o
o

0
1-3
3-5
Everyday

30. For how long do you exercise?

o
o
o
o

Less than 20 minutes

20- 30 minutes
Longer than 30 minutes
I do not exercise

31. What type of exercise do you do (check all that apply)?

o Cardio
o Weight training
o Stretching exercises
32. Are you on a special diet?
o Yes
o No
32a. If yes, what diet?
o
o
o
o
o

Diabetic
Low salt
Cardiac
Renal
High protein

32b. How often do you follow your special diet?

o
o
o
o

Always
Most days
Some days
Never

32c. If not on a special diet, how many servings of fruits/vegetables do you eat per day?
o
o
o
o

None
1-3
3-5
More than 5

Unsafe Sex:
33. Have you had unsafe sex in the last year?
o Yes
o No
7

33a. If yes, how often did you have unsafe sex in the past year?

o
o
o
o

Once
More than five times
More than ten times
More than twenty times