University of San Francisco California
Housing Quality Questions
AAFP Social Needs Screening Tool
Think about the place you live. Do you have problems with any of the following? (check all that apply)
Bug infestation
Mold
Lead paint or pipes
Inadequate heat
Oven or stove not working
No or not working smoke detectors
Water leaks
None of the above
Accountable Health Communities Health-Related Social Needs Screening Tool
Think about the place you live. Do you have problems with any of the following? CHOOSE ALL THAT APPLY
Pests such as bugs, ants, or mice
Mold
Lead paint or pipes
Lack of heat
Oven or stove not working
Smoke detectors missing or not working
Water leaks
None of the above
Arlington Screening Tool
Think about the place you live. Do you have problems with any of the following?
CHOOSE ALL THAT APPLY
• Pests such as bugs, ants, or mice
• Mold
• Lead paint or pipes
• Lack of heat
• Oven or stove not working
• Smoke detectors missing or not working
• Water leaks
• None of the above
HealthBegins Upstream Risk Screening Tool
In the last month, have you had concerns about the condition or quality of your 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)
Total Health Assessment Questionnaire for Medicare Members (KP)
Does the place where you live have the following safety concerns?
No working smoke alarm in one or more bedrooms or levels
Poor lighting or lack of hand rails on stairs
Slippery flooring in the tub or shower or no grab bars
Structural Vulnerability Assessment Tool
Is the place where you live/stay clean/private/quiet/protected by a lease?
Kaiser Permanente's Your Current Life Situation Survey
Do you have any concerns about your current living situation, like housing conditions, safety, and costs?
Condition of housing