Housing Insecurity / Instability / Homelessness Questions

AAFP Social Needs Screening Tool

 Are you worried or concerned that in the next two months you may not have stable housing that you own, rent, or stay in as a part of a household?
Yes/No

Accountable Health Communities Health-Related Social Needs Screening Tool

What is your living situation today?
I have a steady place to live
I have a place to live today, but I am worried about losing it in the future
I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park)

Arlington Screening Tool

Are you worried that in the next 2 months, you may not have stable housing?
Yes/ No

Boston Medical Center-Thrive Screening Tool

Do you currently live in a shelter or have no steady place to sleep at night?
Yes/ No

Do you think you are at risk of becoming homeless?
Yes/ No

HealthBegins Upstream Risk Screening Tool

In the last month, have you slept outside, in a shelter, or in a place not meant for sleeping?
Yes/No

In the last 12 months, how many times have you or your family moved from one home to another?

Health Leads Social Needs Screening Toolkit

Are you worried that in the next 2 months, you may not have stable housing?
Yes/No

Medical-Legal Partnership IHELLP

Please indicate which of the following describe a problem(s) with your housing situation. You may select none or more than one answer:
Bugs (e.g. roaches) or rodents
General cleanliness
Landlord disputes
Lead paint
Unreliable utilies (e.g. electricity, gas, heat)
Medical condition that makes it difficult to live in current house
Mold or dampness
Overcrowding
Threat of eviction
Other (please specify)

Are you living in section 8/public housing?
Yes/No

Total Health Assessment Questionnaire for Medicare Members (KP)

Which of the following best describes where you currently live?
Apartment, condo, trailer, house, townhouse, etc. (a living situation where meals and household help are not routinely provided by paid staff)
Assisted living, retirement facility, etc. (a living situation where meals and household help are routinely provided by paid staff)
Nursing Home (a living situation where nursing care is provided 24 hours a day)
Other

North Carolina Medicaid Screening Tool

Within the past 12 months, have you ever stayed: outside, in a car, in a tent, in an overnight shelter, or temporarily in someone else’s home (i.e. couch-surfing)?
Yes/ No

Are you worried about losing your housing?
Yes/ No

PRAPARE

What is your housing situation today?
I have housing
I do not have housing (staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, or in a park)
I choose not to answer this question

Are you worried about losing your housing?
Yes/No

Structural Vulnerability Assessment Tool

Do you have a safe, stable place to sleep and store your possessions?
How long have you lived/ stayed there?

WellRx Toolkit

Are you homeless or worried that you might be in the future?
Yes/No

Kaiser Permanente's Your Current Life Situation Survey

Which of the following best describes your current living situation? (Select ONE only)
Live alone in my own home (house, apartment, condo, trailer, etc.); may have a pet
Live in a household with other people
Live in a residential facility where meals and household help are routinely provided by paid staff (or could be if requested)
Live in a facility such as a nursing home which provides meals and 24-hour nursing care
Temporarily staying with a relative or friend
Temporarily staying in a shelter or homeless
Other

Do you have any concerns about your current living situation, like housing conditions, safety, and costs?
Yes
No
If YES:
Condition of housing
Lack of more permanent housing
Ability to pay for housing or utilities
Feeling safe
Other

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