Social Influencers of Health Screening Tool (SIOH)

Patient's Name

Date Completed

Name of Person Completing the Screening

Relationship to the Patient

1. In the past 3 months, have you or your family experienced any concerns related to housing, food, transportation, utilities or safety?

Yes No Refused

2. In the past 3 months, has the electric, gas, oil, or water company threatened to shut off services in your home?

Yes No Refused

3. In the past 3 months, has lack of transportation kept you from meetings, work, or from getting things needed for daily living?

Yes No Refused

4. In the past 3 months, was there a time when you worried that your food would run out before you got the money to buy more?

Yes No Refused

5. Do you feel unsafe in your home and/or your neighborhood?

Yes No Refused

6. If you answered yes to any of the questions - Would you like help with any of these needs?

Yes No Refused