Health Screening Form

Patient Information

This information will be sent to your provider and will be kept as part of your patient records.

First Name:

Last Name:

Email Address:

Mobile phone number:

Date of Birth:

Check in the box if your answer is "Yes"

Within the past 12 months, did you worry that your food would run out before you got money to buy more?
Within the past 12 months, did the food you brought just not last and you didn't have money to get more?
Within the past 12 months, have you ever stayed: outside, in a car, in a tent, in an overnight shelter, or temporarily in someone else's home (i.e couch surfing)?
Are you worried about losing your housing?
Within the past 12 months, have you been unable to get utilities (heat, electricity) when it was really needed?
Within the past 12 months, has lack of transportation kept you from medical appointments or from doing things needed for daily living?
Do you feel physically or emotionally unsafe where you live currently?
Within the past 12 months, have you been hi, slapped, kicked or otherwise physically hurt by anyone?
Within the past 12 months, have you been humiliated or emotionally abused by anyone?
Are any of your needs urgent? For example, you don't have food tonight, you don't have a place to sleep tonight, you are afraid you will get hurt if you go home today.
Would you like help with any of these that you have identified?