University of San Francisco California
Social Support Questions
Accountable Health Communities Health-Related Social Needs Screening Tool
Supplemental: If for any reason you need help with day-to-day activities such as bathing, preparing meals, shopping, managing finances, etc., do you get the help you need?
I don’t need any help
I get all the help I need
I could use a little more help
I need a lot more help
Supplemental: How often do you feel lonely or isolated from those around you?
Never
Rarely
Sometimes
Often
Always
ACORN Screening Tool
How often do you feel lonely or isolated from those around you?
Often
Sometimes
Never
Arlington Screening Tool
Do you often feel that you lack companionship?
Yes/ No
HealthBegins Upstream Risk Screening Tool
What is your marital status? Check one.
Married
Living with partner
Widowed
Divorced
Separated
Never married
In a typical week, how many times do you talk on the telephone with family, friends, or neighbors?
How often do you get together with friends or relatives?
How often do you attend religious or faith-based services?
How often do you attend meetings of the clubs or organizations you belong to?
Health Leads Social Needs Screening Toolkit
I often feel that I lack companionship.
Yes/No
Total Health Assessment Questionnaire for Medicare Members (KP)
Do you have someone you could call if you needed help?
Yes/No
National Academy of Medicine Domains
In a typical week, how many times do you talk on the telephone with family, friends, or neighbors?
How often do you get together with friends or relatives?
How often do you attend church or religious services?
How often do you attend meetings of the clubs or organizations you belong to?
PRAPARE
How often do you see or talk to people that that you care about and feel close to? (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)
Less than once a week
1 or 2 times a week
3 to 5 times a week
5 or more times a week
Structural Vulnerability Assessment Tool
Do you have friends, family, or other people who help you when you need it?
Who are the members of your social network, family and friends?
Do you feel this network is helpful or unhelpful to you?
In what ways?
Kaiser Permanente's Your Current Life Situation Survey
If for any reason you need help with activities of daily living such as bathing, preparing meals, shopping, managing finances, etc., do you get the help that you need?
I don’t need any help
I get all the help I need
I could use a little more help
I need a lot more help
Optional: Do you have somene you could call if you needed help?
Yes
No
Optional: How often do you feel lonely or isolated from those around you?
Never
Rarely
Sometimes
Often
Always
Optional: How often do you see or talk to people that you care about and feel close to? (For example, talking to friends on the phone, visiting friends and family, going to church or club meetings)
Less than once a week
1-2 days a week
3-4 days a week
5 or more days a week