Topics:
(1) food: questions 1 and 2
(2) housing and utilities: questions 3, 4 and 5
(3) transportation: question 6
(4) interpersonal safety: questions 7, 8 and 9
(5) urgent needs (optional): question 10
Questions:
(1) Within the past 12 months, did you worry that your food would run out before you got money to buy more?
(2) Within the past 12 months, did the food that you bought just not last and you didn't have money to get more?
(3) Do you have housing?
(4) Are you worried about losing your housing?
(5) Within the past 12 months, have you or your family members you live with been unable to get utilities (heat, electricity) when it was really needed?
(6) Within the past 12 months, has lack of transportation kept you from medical appointments, getting your medicine, non-medical meetings or appointments, work, or from getting things that you need?
(7) Do you feel physically and emotionally safe where you currently live?
(8) Within the past 12 months, have you been hit, slapped, kicked or otherwise physically hurt by someone?
(9) Within the past 12 months, have you been physically humiliated or emotionally abused in other ways by your partner or ex-partner?
(10) Are any of your needs urgent? For example, I don't have food for tonight; I don't have a place to sleep tonight; I am afraid that I will get hurt if I go home today?
where:
• In the original numbering there was no question 3. The numbering above is in response.
|
Response (except 3 and 7)
|
Points
|
|
no
|
0
|
|
yes
|
1
|
|
Response (3 and 7)
|
Points
|
|
no
|
1
|
|
yes
|
0
|
total score =
= SUM(points for all 10 questions)
Interpretation:
• minimum score: 0
• maximum score: 10
• The higher the score the greater the needs of the patient.
