SDH Screen Youth (18 and Under) SDH Screen Youth (18 and Under) SDH Screen Youth (18 and Under) Social Determinants of Health Screening (Youth) Health starts in our homes, schools, and jobs. When we know more about you, we can provide better care to support your health and wellness. Name * Date of Birth * 1. How hard is it for you to pay for the very basics like food, housing, heating, medical care, and medications? * Not hard at all Somewhat hard Very hard Decline 2. What is your living situation today? (Check one) * I have a steady place to live I have steady place to live, but I am worried about losing it in the future I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, or in a park.) Decline 3. Think about the place you live. Do you have problems with any of the following? (Check all that apply) * Pests such as bugs, ants, or mice Mold Lead paint or pipes Lack of heat Oven or stove not working Smoke detectors missing or not working Water leaks None of the above Decline 4. In the past 12 months, has lack of transportation kept you from medical appointments, meetings, work or from getting things needed for daily living? (Check all that apply) * Yes, it has kept me from medical appointments or from getting medications Yes, it has kept me from non-medical meetings, appointments, work, or getting things that I need No Decline 5. How often do you see or talk to people that you care about and feel close to? (For example: talking to friends on phone, visiting friends or family, going to church or club meetings) * Less than once a week 1-2 times a week 3-5 times a week 5 or more times a week Decline FINANCIAL RESOURCE STRAIN 6. If you marked somewhat or very hard on the first question of this survey, please check all that are hard to pay for. * Food Utilities Transportation Clothing Medicine or medical care Health insurance Rent/Mortgage Childcare Phone Other If you answered “Other” above, please explain: FOOD Some people have made the following statements about their food situation. Please answer whether the statements were OFTEN, SOMETIMES, or NEVER true for you and your household in the last 12 months. 7. Within the past 12 months, you worried that your food would run out before you got money to buy more? * Often true Sometimes true Never true Decline 8. Within the past 12 months, the food you bought just didn’t last and you didn’t have money to get more? * Often true Sometimes true Never true Decline UTILITIES 9. In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home? * Yes No Already shut off Decline PHYSICAL ACTIVITY 10. On average, how many days per week do you engage in moderate to strenuous exercise? (Check one) * 1 2 3 4 5 6 7 11. On average, how many minutes do you engage in exercise at this level? (Use the slider to indicate minutes) * 75 STRESS Stress means a situation in which a person feels tense, restless, nervous, or anxious, or is unable to sleep at night because his or her mind is troubled all the time. 12. Do you feel these kinds of stress these days? * Not at all A little bit Somewhat Quite a bit Very much Decline SOCIAL ISOLATION 13. How often do you feel lonely or isolated from those around you? * Never Rarely Sometimes Often Always Decline 14. Do you have someone you could call if you needed help? * Yes No Decline RELATIONSHIP SAFETY Because violence and abuse happen to a lot of people and affects their health, we are asking the following questions. 15. How often does anyone, including family and friends, physically hurt you? * Never Rarely Sometimes Fairly often Frequently Decline 16. How often does anyone, including family and friends, insult or talk down to you? * Never Rarely Sometimes Fairly often Frequently Decline 17. How often does anyone, including family and friends, threaten you with harm? * Never Rarely Sometimes Fairly often Frequently Decline 18. How often does anyone, including family and friends, scream or curse at you? * Never Rarely Sometimes Fairly often Frequently Decline EMPLOYMENT 19. Are you currently employed? * Yes No Decline IF YES: What is your current work situation? Full Time Part Time or Temporary Decline Are you having any problems with your boss? Yes No Decline IF NO: Are you seeking work? Yes No Decline Would you like help finding a job? Yes No Decline Would you like to be connected to job training resources? Yes No Decline Would you like information about language classes or other educational opportunities? Yes No 20. Would you like assistance with any of the following (check all that apply)? * Financial Strain Housing Food Transportation Utilities Physical Activity Stress Social Isolation Relationship Safety IF YES: How would you like to be contacted? In person, during an appointment By phone By text If you are human, leave this field blank. Submit
