Upstream Risks Screening Tool

“Everyone deserves the opportunity to have a safe, healthy place to live, work, eat, sleep, learn and play. Problems or stress in these areas affect health. We ask our patients about these issues because we may be able to help.

Date of screening: ___/___/______

What’s your name? First: Last: / What’s your date of birth? ___/___/______
  1. Education
  2. What is the highest level of school you have completed?
  3. Elementary school
  4. High school
  5. College
  6. Graduate / Professional school
  7. What is the highest degree you earned?
  8. High school diploma
  9. GED
  10. Vocational certificate (post high school or GED)
  11. Associate’s degree (junior college)
  12. Bachelor’s degree
  13. Master’s degree
  14. Doctorate
  15. Are you concerned about your child’s learning, performance, or behavior in school?
  16. YES
  17. NO
  18. Not applicable
  19. Employment
  20. Choose one of the following. Which best describes your current occupation?
  21. Homemaker
  22. Employed full-time
  23. Employed part time
  24. Employed, but on leave for health reasons
  25. Employed but temporarily away from my job (other than health reasons
  26. Unemployed or laid off 6 months or less
  27. Unemployed or laid off more than 6 months
  28. Unemployed due to disability
  29. Retired from my usual occupation and not working
  30. Retired from my usual occupation but working for pay
  31. Retired from my usual occupation but volunteering
  32. Social Connection & Isolation
  33. What is your marital status? Check one.
  34. Married
  35. Living with partner
  36. Widowed
  37. Divorced
  38. Separated
  39. Never married
  40. Social Connection & Isolation
  41. In a typical week, how many times do you talk on the telephone with family, friends, or neighbors?
  42. Number of times per week _____
  43. How often do you get together with friends or relatives?
  44. Number of times per week _____
  45. How often do you attend religious or faith-based services?
  46. Number of times per year _____
  47. How often do you attend meetings of the clubs or organizations you belong to?
  48. Number of times per year _____
  49. Physical Activity
  50. On average, how many days per week do you engage in moderate to strenuous exercise (like walking fast, running, jogging, dancing, swimming, biking, or other activities that cause a light or heavy sweat)?
  51. Days per week ______
  52. On average, how many minutes do you engage in exercise at this level?
  53. 0
  54. 10
  55. 20
  56. 30
  57. 40
  58. 60
  59. 90
  60. 120
  61. 150 or greater
  62. Immigration
  63. Do you have concerns about any immigration matter for you or your family?
  64. YES
  65. NO
  1. Financial Strain
  2. Do you ever have problems making ends meet at the end of the month?
  3. YES
  4. NO
  5. How hard is it for you to pay for the very basics like food, housing, medical care, and heating? Would you say it is:
  6. Very hard
  7. Somewhat hard
  8. Not hard at all
  9. Housing Insecurity
  10. In the last month, have you slept outside, in a shelter, or in a place not meant for sleeping?
  11. YES
  12. NO
  13. In the last month, have you had concerns about the condition or quality of your housing?
  14. YES
  15. NO
  16. In the last 12 months, how many times have you or your family moved from one home to another?
  17. ______
  18. Food Insecurity
  19. Which of the following describes the amount of food your household has to eat:
  20. Enough to eat
  21. Sometimes not enough to eat
  22. Often not enough to eat
  23. Dietary Pattern
  24. How many pieces of fruit, of any sort, do you eat a typical day?
  25. ______pieces/day
  26. How many portions of vegetables, excluding potatoes, do you eat on a typical day?
  27. ______portions/day
  28. Transportation
  29. How often is it difficult to get transportation to or from your medical or follow-up appointments?
  30. Does not apply
  31. Never
  32. Sometimes
  33. Often
  34. Always
  35. Exposure to Violence
  36. Do you have concerns about safety in your neighborhood?
  37. YES
  38. NO
  39. Exposure to Violence
  40. Within the last year, have you been humiliated or emotionally abused in other ways by your partner or ex-partner?
  41. YES
  42. NO
  43. Within the last year, have you been afraid of your partner or ex-partner?
  44. YES
  45. NO
  46. Within the last year, have you been raped or forced to have any kind of sexual activity by your partner or ex-partner?
  47. YES
  48. NO
  49. Within the last year, have you been kicked, hit, slapped, or otherwise physically hurt by your partner or ex-partner?
  50. YES
  51. NO
  52. Stress
  53. Stress means a situation in which a person feels tense, restless, nervous, or anxious, or is unable to sleep at night because his/her mind is troubled all the time. Do you feel this kind of stress these days?
  54. Not at all
  55. A little bit
  56. Somewhat
  57. Quite a bit
  58. Very much
  59. Civic Engagement
  60. Would you like help registering to vote?
  61. YES
  62. NO

Name of screener: Survey #: