SOCIAL HEALTH INVENTORY

This survey is designed to help medical providers direct patients to needed services and evaluate needs of the community. You may leave any question blank or answer as many as you’d like.

 
Phone
Phone
Do any of the following describe your current housing situation?
(leave blank if you have stable housing)
Does your housing have any problems with any of the following?
(check any and all that apply)
If you do not have a traditional "home," please indicate how many people live with you regularly as a "family unit," including yourself.
Please indicate which of the following (if any) describe a problem with your child's education:
Leave blank if none apply or you do not have children.
In the past 12 months, have you been unable to attend any of the following due to lack of adequate transportation:
Leave blank if none apply.
Please check any and all that apply regarding your financials:
Leave blank if none apply.
Please check any and all that apply regarding your personal and/or family stability:
Leave blank if none apply.