SDoH Form

1. What is your housing situation today? I have housing I do not have housing (staying with others, hotel, shelter, living outside, car, or park) I choose not to answer this question

2. In the past 2 months, did you or others you live with eat smaller meals or skip meals because you didn't have money for food? Yes No

3. 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? Yes No Already Shut Off

4. In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home? Yes No Already Shut Off

5. Do you feel unsafe in your daily life? Yes No

6. Are you unemployed or without regular income? Yes No

7. How often do you feel that you lack companionship? Never Rarely Sometimes Always

Use this form to request assistance from Peach State Health Plan.