SOCIAL DETERMINANTS OF HEALTH (SDOH) QUESTIONNAIRE

Yes
Did you graduate from High School?
Yes
Are you comfortable using a computer?
Yes
If able to work, do you have a steady job?
Yes
Do you feel safe from toxins/hazards/dangers in your job?
Yes
Do you feel safe at home?
Yes
Do you/your immediate family have access to enough food every day?
Yes
Do you/your immediate family have a safe place to live each day?
Yes
Are you/your immediate family able to afford basic needs such as food, housing, telephone, gas/electric?
No
Have you/your immediate family ever decided not to see a doctor or fill a medication because it was too expensive?
Yes
Do you have someone whom you trust and to whom you can go with personal difficulties?
Yes
Do you have someone whom you trust to help take care of you when you are sick?
Yes
Do you feel safe (physically, financially, and emotionally)?
No
Do you need legal assistance for anything (child & family services, housing, immigration, discrimination, domestic issues)?
Yes
Do you have access to transportation on a daily basis?
No
Have you ever missed a medical appointment because you couldn’t get a ride?
Yes
Do you have access to adequate medical care in your community?
No
Do you have problems remembering to take your medications?
No
Do you feel down, depressed, hopeless, or anxious?

Z Codes