SDoH - HRSN - Health Behavior Assessment and Intervention (HBAI)

HRsN Assesment Form

Client Information

NOTE: THE IDENTIFIER IS CASE SENSITIVE. MUST USE EXACT SPELLING TO LOCATE
Client Name
Client Name
First
Last
Address
Address
City
State/Province
Zip/Postal
Country
Ethnicity/Culture
Gender
Serving a Client Household
Is a FFN Provider *
Is a Solid Ground Client *
Are You Training to be Community Support Worker *
Check Services Client would Like Receive

Your Community

Select Clients Community *

Living Situation

1. What is your living situation today? *
2. Think about the place you live. Do you have problems with any of the following? *

Food

Some people have made the following statements about their food situation. Please
answer whether the statements were OFTEN, SOMETIMES, or NEVER true for you and
your household in the last 12 months.

3. Within the past 12 months, you worried that your food would run out before you got money to buy more. *
4. Within the past 12 months, the food you bought just didn't last and you didn't have money to get more. *

Transportation

5. In the past 12 months, has lack of reliable transportation kept you from medical appointments, meetings, work or from getting things needed for daily living? *

Utilities

6. In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home? *

Safety

Because violence and abuse happens to a lot of people and affects their health we are
asking the following questions.

7. How often does anyone, including family and friends, physically hurt you? *
8. How often does anyone, including family and friends, insult or talk down to you? *
9. How often does anyone, including family and friends, threaten you with harm? *
10. How often does anyone, including family and friends, scream or curse at you? *

Financial Strain

11. How hard is it for you to pay for the very basics like food, housing, medical care, and heating? Would you say it is: *
Can Sisters In Common (we) share your name, phone number, address, and email to get you the help and services, you are asking for?

Employment

12. Do you want help finding or keeping work or a job? *

Family and Community Support

13. 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? *
14. How often do you feel lonely or isolated from those around you? *

Education

15. Do you speak a language other than English at home? *
16. Do you want help with school or training? For example, starting or completing job training or getting a high school diploma, GED or equivalent. *

Physical Activity

17. In the last 30 days, other than the activities you did for work, on average, how many days per week did you engage in moderate exercise (like walking fast, running, jogging, dancing, swimming, biking, or other similar activities)? *
18. On average, how many minutes did you usually spend exercising at this level on one of those days? *

Substance Use

The next questions relate to your experience with alcohol, cigarettes, and other drugs. Some of the substances are prescribed by a doctor (like pain medications), but only count those if you have taken them for reasons or in doses other than prescribed. One question is about illicit or illegal drug use, but we only ask in order to identify community services that may be available to help you.

19. How many times in the past 12 months have you had 5 or more drinks in a day (males) or 4 or more drinks in a day (females)? One drink is 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof spirits. *
20. How many times in the past 12 months have you used tobacco products (like cigarettes, cigars, snuff, chew, electronic cigarettes)? *
21. How many times in the past year have you used prescription drugs for non-medical reasons? *
22. How many times in the past year have you used illegal drugs? *

Mental Health

23. Over the past 2 weeks, how often have you been bothered by any of the following problems?

23a. Little interest or pleasure in doing things? *
23b. Feeling down, depressed, or hopeless? *
24. Stress means a situation in which a person feels tense, restless, nervous, or anxious, or is unable to sleep at night because his or her mind is troubled all the time. Do you feel this kind of stress these days? *

Disabilities

25. Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions? (5 years old or older) *
26. Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping? (15 years old or older) *

Health Behaviors Triggers and Management

In the past 12 months, which of the following have triggered stress or anxiety for you? (Select all that apply)
How do you typically manage stress or anxiety?

Ready to do something (behavior change)

On a scale of 1 to 5, how ready are you to make changes in your behavior to improve your health?
What barriers do you feel might stop you from making these changes?

Mental Problem History

Have you ever been diagnosed with a mental health problem (e.g., anxiety, depression, substance use disorder)?

Support System

Do you have a support system in place to help you with your health goals?

Service Preferences

What types of services are you most interested in receiving to support your health goals? (Select all that apply)

Follow-up and Consent

Would you like help your health goals?

Health Behavior Interventions

Which of the following health behavior interventions have you participated in or are interested in? (Select all that apply)

Outcome Expectations

On a scale of 1 to 5, how confident are you that the services and support provided will help you achieve your health goals?

Covid 19 Related Information

Have you, or anyone in your family, ever been impacted by Covid?
(Examples, money problem, food, housing, utilities, car, job, health, family, deaths,...)
Have you tested positive for Covid 19?
If you said yes to testing positive in previous question what type of test was it?

Health Insurance

Client has Health Insurance with one of the following
Primary Insured Name (if different from Client)
Primary Insured Name (if different from Client)
First
Last
I Need Health Insurance

Support Contact Information

You must give the identifer to the Sisters In Common staff member who calls regarding this screening.

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