This screening form helps healthcare teams identify social and economic needs that may affect a patient’s health, well-being, or ability to access care. It can support standardized screening for needs such as food, housing, transportation, utilities, financial strain, safety, and access to other essential resources. Practices can use the form to guide patient-centered conversations, document identified needs, and determine whether a patient would like assistance. Screening should be paired with clear response protocols, staff training, appropriate privacy protections, and workflows for referral, follow-up, and connection to community services.
The Word Doc version below can be customized with your own logo.