Health Leads Screening

Name:

Phone number:

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Best time to call:

In the last 12 months, did you ever eat less than you felt you should because there wasn’t enough money for food?

Not selected
YES
NO

In the last 12 months, has your utility company shut off your service for not paying your bills?

Not selected
YES
NO

Are you worried that in the next 2 months, you may not have stable housing?

Not selected
YES
NO

Do problems getting child care make it difficult for you to work or study? (leave blank if you do not have children)

Not selected
YES
NO

In the last 12 months, have you needed to see a doctor, but could not because of cost?

Not selected
YES
NO

In the last 12 months, have you ever had to go without health care because you didn’t have a way to get there?

Not selected
YES
NO

Do you ever need help reading hospital materials?

Not selected
YES
NO

Are you afraid you might be hurt in your apartment building or house?

Not selected
YES
NO

If you checked YES to any boxes above, would you like to receive assistance with any of these needs?

Not selected
YES
NO

Are any of your needs urgent? For example: I don’t have food tonight, I don’t have a place to sleep tonight

Not selected
YES
NO

FOOD INSECURITY

In the last 12 months, did you ever eat less than you felt you should because there wasn’t enough money for food?

Not selected
YES
NO

In your household, within the last 12 months, the food that we bought just didn’t last, and we didn’t have money to get more.

Not selected
Often True
Sometimes True
Never True

Within the past 12 months we worried whether our food would run out before we got money to buy more.

Not selected
YES
NO

Within the last 12 months, we couldn’t afford to eat balanced meals.

Not selected
Often True
Sometimes True
Never True

In the past year, have you ever used a Food Pantry/Soup Kitchen or received a food donation?

Not selected
YES
NO

HOUSING INSTABILITY

Are you worried or concerned that in the next two months you may not have stable housing that you own, rent, or stay in as a part of a household?

Not selected
YES
NO

In the last month, have you slept outside, in a shelter, or in a place not meant for sleeping?

Not selected
YES
NO

Do you think you are at risk of becoming homeless?

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YES
NO

An eviction is when your landlord or a government or bank official forces you to move when you don’t want to. In the past five years have you ever been evicted?

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YES
NO

How often in the past 12 months would you say you were worried or stressed about having enough money to pay your rent/mortgage?

Not selected
Always
Usually
Sometimes
Rarely
Never

UTILITY NEEDS

In the past year, has the utility company shut off your service for not paying your bills?

Not selected
YES
NO

Do you have trouble paying your heating bill for the winter?

Not selected
YES
NO

Have you used your cooking stove for heat?

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YES
NO

Since [name of current month] of last year, were there any days that your home was not heated because you couldn’t pay the bills?

FINANCIAL RESOURCE STRAIN

In the last 12 months, was there a time when you needed to see a doctor but could not because of cost?

Not selected
YES
NO

In the last 12 months, did you skip medications to save money?

Not selected
YES
NO

Please indicate how often this describes you: I don’t have enough money to pay my bills

Not selected
Never
Rarely
Sometimes
Often
Always

Sometimes people find that their income does not quite cover their living costs. In the last 12 months, has this happened to you?

Not selected
YES
NO

TRANSPORTATION

In the last six months, have you ever had to go without health care because you didn’t have a way to get there?

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YES
NO

Do you put off or neglect going to the doctor because of distance or transportation? (

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YES
NO

Does lack of money for transportation expenses, such as parking, make it difficult to get to the doctor or dentist?

Not selected
Very Difficult
Difficult
Easy
Very Easy

Are you regularly able to get a friend or relative to take you to doctor’s appointments?

Not selected
YES
NO

EXPOSURE TO VIOLANCE

Are you afraid you might be hurt in your apartment building or house?

Not selected
YES
NO

CHILDCARE

Do problems getting child care make it difficult for you to work or study?

Not selected
YES
NO

Do your children usually get the breakfast that their school provides?

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YES
NO

During the past two years have you had a child care subsidy taken away?

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YES
NO

In the past three months, how often have you experienced child care breakdowns?

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Often
Sometimes
Rarely
Never

My family needs diapers, clothing, car seats and/or back to school supplies.

Not selected
YES
NO

Would availability of child care affect hours spent/attendance at schooling, training, employment or job search?

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YES
NO

EDUCATION

Do you ever need help reading hospital materials

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YES
NO

Do you have a high school degree?

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YES
NO

What is the highest level of schooling you have completed?

How confident are you filling out medical forms by yourself?

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Extremely
Quite a bit
Somewhat
A little bit
Not at all

How often do you have a problem understanding what is told to you about your medical condition?

Not selected
Always
Often
Sometimes
Occasionally
Never

EMPLOYMENT

During the last four weeks, have you been actively looking for work?

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YES
NO

Last week, did you work for pay at a job (or business)?

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YES
NO

What was your main activity during most of the last 12 months?

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Worked for Pay
Attended School
Household Duties
Unemployed
Permanently Unable to Work
Other

Do you need help finding a local career center and/or job training program?

Not selected
YES
NO

Do you have a job?

Not selected
YES
NO

Do you have a disability that prevents you from accepting any kind of work during the next six months?

Not selected
YES
NO

There are required fields in this form marked .