SDOH Form

Name:

Date of Birth:

How can we help?

Answer the questions below and your provider will discuss them with you during your appointment.

Do you need help finding a doctor or clinic for yourself?

Concerns/problems that make it hard to keep your child’s doctor appointments or manage their healthcare

In the last 3 months, have you felt stressed about making ends meet of having enough food?

Are you worried about benefits right now?

Do you have concerns about your child’s education needs?

Yes No

If yes, specify:

Do you have concerns about your housing or becoming homeless?

Yes No

If yes, specify:

Do you want to talk to someone about feeling alone or needing someone to rely on when you have problems?

Yes No

If yes, specify:

Do you, or anyone else in your home use medicine not prescribed to you, or any other type of drugs?

Yes No

If yes, specify:

In the past year, has anyone threatened, hit, slapped or touched you or your child is an unwanted way?

Yes No

If yes, specify:

Do you feel sad, hopeless or anxious a lot of the time?

Yes No