SDOH

1
How We Protect Your Information and Support Your Needs

This form helps us understand your social needs, such as housing, food, and access to healthcare, so we can better support your overall well-being. Your information is protected and kept private under HIPAA compliance, ensuring your data is secure. Based on your answers, we will recommend services and resources that may be helpful to you. Our goal is to connect you with the support you need to improve your health and quality of life.
2
Community Caregiver Email Address* This field is required.
example@example.com
3
Community Caregiver Phone Number:* This field is required.We will send SMS messages to this number based on responses from organizations
4
Patient / Family Member Opt-In* This field is required.Do you agree to receive SMS messages ensuring services were delivered to the patient? Opt-out anytime.
YESNO
5
Patient / Family Member Mobile Number* This field is required.For sending SMS messages about services rendered ('Closing The Loop')
6
Patient's Full Name* This field is required.
First Name
Last Name
7
What is your preferred language?* This field is required.So that we may contact you and ensure services were received
Please Select
Please Select
English — eng
廣東話 — yue
日本語 — jpn
한국어 — kor
国语 — zho
Chuukese — chk
ʻŌlelo Hawaiʻi Hawaiian — haw
Ilokano — ilo
Marshallese — mah
Samoan — smo
Español — spa
Tagalog — tgl
Tongan — ton
ภาษาไทย — tha
Tiếng Việt — vie
Visayan — ceb
8
What was your gender assigned at birth?* This field is required.
Male
Female
Prefer Not To Answer
9
Age Range
Please Select
Please Select
10 years old or less
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
66-70
71-75
76-80
81-85
86-90
90 years old ore more
10
Do you have concerns about falling in your home?* This field is required.
YESNO
11
Are you at least 18 years old?* This field is required.
YESNO
12
Please enter your Zip Code where you live:* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
13
Select the region where you reside:* This field is required.
Central Oahu
Downtown / Waikiki
North Shore
West Side
East Oahu
Windward Side
14
Is the patient currently in the ER?* This field is required.
YESNO
15
Is your housing situation unsafe and / or unstable?* This field is required.SDOH Category: Stable Housing
YESNO
16
Do you struggle to eat a healthy diet (daily fruits and vegetables)?* This field is required.SDOH Category: Access to Healthy Foods
YESNO
17
Are you unable to pay your bills because of not enough income?* This field is required.SDOH Category: Income & Employment
YESNO
18
Do you have difficulty understanding forms or instructions?* This field is required.SDOH Category: General Education
YESNO
19
Is it difficult to understand what your doctor says about your health?* This field is required.SDOH Category: Medical Literacy
YESNO
20
Do you lack someone to talk to or ask for help?* This field is required.SDOH Category: Community Support
YESNO
21
Is it difficult to visit the doctor due to transportation needs?* This field is required.SDOH Category: Access to Health Care
YESNO
22
Do you feel unsafe or unsupported by your family?* This field is required.SDOH Category: Family Dynamics
YESNO
23
Did you grow up in a home where you felt unsafe and / or neglected?* This field is required.SDOH Category: Childhood & Upbringing
YESNO
24
Aggregate Score
25
Medical Literacy or General Education
26
Age Score
27
Have you ever used Alcohol, Drugs, or Medication in a way that wasn't for health reasons?* This field is required.Substance Use
YESNO
28
Has this ever caused problems for you?* This field is required.
YESNO
29
Do you often feel lonely or isolated from others?* This field is required.Mental Health
YESNO
30
Do you feel comfortable reaching out to others for support when you need it?* This field is required.Mental Health
YESNO
31
Are you currently pregnant or planning to become pregnant in the next 6 months?* This field is required.Pregnancy Concerns
YESNO
Should be Empty: