Social Determinants of Health

Help us understand your daily needs.

Accountable Health Communities Health-Related Social Needs (HRSN) Screening Tool. Your answers are confidential and will help us connect you with community resources.

1. What is your living situation today?
2. Think about the place you live. Do you have problems with any of the following?

Select all that apply

Food
3. Within the past 12 months, you worried that your food would run out before you got money to buy more.
4. Within the past 12 months, the food you bought just didn't last and you didn't have money to get more.
Transportation
5. In the past 12 months, has lack of reliable transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?
Utilities
6. In the past 12 months, has the electric, gas, oil, or water company threatened to shut off services in your home?
Safety
7. How often does anyone, including family and friends, physically hurt you?
8. How often does anyone, including family and friends, insult or talk down to you?
9. How often does anyone, including family and friends, threaten you with harm?
10. How often does anyone, including family and friends, scream or curse at you?
Supplemental Questions
Financial Strain
11. How hard is it for you to pay for the very basics like food, housing, medical care, and heating?
Employment
12. Do you want help finding or keeping work or a job?
Family and Community Support
13. If for any reason you need help with day-to-day activities such as bathing, preparing meals, shopping, managing finances, etc., do you get the help you need?
14. How often do you feel lonely or isolated from those around you?
Education
15. Do you speak a language other than English at home?
16. Do you want help with school or training? For example, starting or completing job training or getting a high school diploma, GED or equivalent.
Physical Activity
17. In the last 30 days, other than the activities you did for work, on average, how many days per week did you engage in moderate exercise (like walking fast, running, jogging, dancing, swimming, biking, or other similar activities)?
18. On average, how many minutes did you usually spend exercising at this level on one of those days?
Substance Use
19. How many times in the past 12 months have you had 5 or more drinks in a day (males) or 4 or more drinks in a day (females)? One drink is 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof spirits.
20. How many times in the past 12 months have you used tobacco products (like cigarettes, cigars, snuff, chew, electronic cigarettes)?
21. How many times in the past year have you used prescription drugs for non-medical reasons?
22. How many times in the past year have you used illegal drugs?
Mental Health
Over the past 2 weeks, how often have you been bothered by any of the following problems?
23. Little interest or pleasure in doing things?
24. Feeling down, depressed, or hopeless?
25. 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. Do you feel this kind of stress these days?
Disabilities
26. Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions? (5 years old or older)
27. Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping? (15 years old or older)

The help you need, right here.

Confidential mental health and substance use care for Chicago's southwest side. Medicaid, Medicare, and uninsured welcome — appointments within 24–48 hours.

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