HUNGER VITAL SIGN SCREEN

Date: [Date]
Patient: [Name or ID, age]
Visit: [Visit type and setting]
Answered by: [Patient, parent or caregiver, or other household member; interpreter if used]
How it was asked: [Read aloud in private, on paper, or on a tablet]

ANSWERS, PAST 12 MONTHS
Statement 1, worried food would run out: [Often true, sometimes true, or never true]
Statement 2, food bought did not last: [Often true, sometimes true, or never true]
Total: [0 to 2 statements often or sometimes true]
Result: [Negative, or positive: at risk for food insecurity]

CONVERSATION
What the household shared: [Recent changes in work, income, housing, or family; skipped meals]
Who is most affected: [Children, an infant on formula, pregnancy, older adults, special diets]
Effect on health: [Blood sugar control, growth and feeding, medicines skipped to pay for food]

RESOURCES AND REFERRALS
Offered: [Food bank and meal program list, help applying for food and income benefits, other]
Referrals: [Social work, community health worker, dietitian, or none]
Household's choice: [What was accepted or declined, and consent to share contact details]

FOLLOW-UP
Next contact: [Who will call or see the household, and when]
Screen again: [Date or visit]

Clinician: [Name, credentials]