. 2022 Jan 17;8(1):e32818. doi: 10.2196/32818

Table 1.

Social Determinants of Health Screening Questionnaire.

Screening questions with “yes/no” response options	Social needs domain
Question 1: “Are you worried that in the next two months you might not have a safe place to live? (eviction, kicked out homelessness)”	Housing instability^a
Question 2: “Are you worried that the place you are living now is making you sick? (has mold, bugs, rodents, water leaks, not enough heat)”	Housing quality^b
Question 3: “In the last 3 months, has the electric, gas, oil or water company threatened to shut off services to your home?”	Utility strain^a
Question 4: “In the last 12 months, did you worry that your food could run out before got money to buy more?”	Food insecurity^a
Question 5: “In the last 3 months, has lack of transportation kept you from medical appointments or getting your medication?”	Transportation^a
Question 6: “In the last 3 months, did you skip buying medication or going to the doctor’s appointment to save money?”	Financial resources strain^a
Question 7: “Do you need help getting childcare or care for an elderly or sick adult?”	Childcare^c
Question 8: “Do you need legal help? (child family services, immigrations, housing, discrimination, domestic issues, etc.)”	Legal^b
Question 9: “Are you finding it so hard to get along with a partner, spouse, or family member that it is causing you stress?”	Behavioral and mental health^c
Question 10: “Does anyone in your like hurt you, threaten you, frighten you or make you feel unsafe?”	Exposure to violence^a

^aThis domain is identified as an essential social needs domain in the Health Leads Toolkit [18].

^bThis domain is identified as an important social needs issue by the multidisciplinary committee of the health system.

^cThis domain is identified as an optional social needs domain in the Health Leads Toolkit [18].