Open the interactive version → Reference copy — the full item bank in reading order.
Instrument sheet · a small set of standard questions

AHC Health-Related Social Needs — every question

All 30 items in reading order, with their exact response options, the scoring rules where the instrument defines one, and the source of every question.

CMS obtained permission from the original question authors for use within the AHC Model and CMS's own use. CMS published a per-question citation and notification table for use outside CMS. Retain the Source field on every item.

Part 1 — Core

10 items · asked of everyone
AHC-01 Living Situation choose one

What is your living situation today?

I have a steady place to live I have a place to live today, but I am worried about losing it in the future positive I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park) positive
Source PRAPARE (NACHC / AAPCHO / OPCA / IAF, 2017)
AHC-02 Housing Quality choose all that apply

Think about the place you live. Do you have problems with any of the following? CHOOSE ALL THAT APPLY

Pests such as bugs, ants, or mice positive Mold positive Lead paint or pipes positive Lack of heat positive Oven or stove not working positive Smoke detectors missing or not working positive Water leaks positive None of the above
Scoring Any selection other than "None of the above" is a positive screen.
Source Nuruzzaman et al., J Health Care Poor Underserved, 2015
AHC-03 Food Insecurity (1 of 2) choose one

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.

Within the past 12 months, you worried that your food would run out before you got money to buy more.

Often true positive Sometimes true positive Never true
Source Hunger Vital Sign — Hager et al., Pediatrics, 2010
AHC-04 Food Insecurity (2 of 2) choose one

Within the past 12 months, the food you bought just didn't last and you didn't have money to get more.

Often true positive Sometimes true positive Never true
Scoring Positive on the food domain if "Often true" or "Sometimes true" is selected on either AHC-03 or AHC-04.
Source Hunger Vital Sign — Hager et al., Pediatrics, 2010
AHC-05 Transportation choose one

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 positive No
Source PRAPARE (NACHC / AAPCHO / OPCA / IAF, 2017)
AHC-06 Utilities choose one

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

Yes positive No Already shut off positive
Source Cook et al., Pediatrics, 2008
AHC-07 Safety (1 of 4) scored scale

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

How often does anyone, including family and friends, physically hurt you?

Never 1 Rarely 2 Sometimes 3 Fairly often 4 Frequently 5
Source HITS — Sherin et al., Family Medicine, 1998
AHC-08 Safety (2 of 4) scored scale

How often does anyone, including family and friends, insult or talk down to you?

Never 1 Rarely 2 Sometimes 3 Fairly often 4 Frequently 5
Source HITS — Sherin et al., Family Medicine, 1998
AHC-09 Safety (3 of 4) scored scale

How often does anyone, including family and friends, threaten you with harm?

Never 1 Rarely 2 Sometimes 3 Fairly often 4 Frequently 5
Source HITS — Sherin et al., Family Medicine, 1998
AHC-10 Safety (4 of 4) scored scale

How often does anyone, including family and friends, scream or curse at you?

Never 1 Rarely 2 Sometimes 3 Fairly often 4 Frequently 5
Scoring Sum AHC-07 through AHC-10. A total of 11 or more indicates the person might not be safe.
Source HITS — Sherin et al., Family Medicine, 1998

Part 2 — Supplemental

16 items across 8 domains
AHC-11 Financial Strain choose one

How hard is it for you to pay for the very basics like food, housing, medical care, and heating? Would you say it is:

Very hard Somewhat hard Not hard at all
Source Hall et al., Sleep, 2009 (SWAN Sleep Study)
No threshold The source defines no positive-screen rule for this item.
AHC-12 Employment choose one

Do you want help finding or keeping work or a job?

Yes, help finding work Yes, help keeping work I do not need or want help
Source AHC Technical Expert Panel, 2016
No threshold The source defines no positive-screen rule for this item.
AHC-13 Family and Community Support (1 of 2) choose one

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?

I don't need any help I get all the help I need I could use a little more help I need a lot more help
Source Kaiser Permanente Medicare Total Health Assessment Questionnaire, 2012
No threshold The source defines no positive-screen rule for this item.
AHC-14 Family and Community Support (2 of 2) choose one

How often do you feel lonely or isolated from those around you?

Never Rarely Sometimes Often Always
Source AARP Research, Loneliness and Social Connections, 2018
No threshold The source defines no positive-screen rule for this item.
AHC-15 Education (1 of 2) choose one

Do you speak a language other than English at home?

Yes No
Source US Census Bureau, American Community Survey, 2017
No threshold The source defines no positive-screen rule for this item.
AHC-16 Education (2 of 2) choose one

Do you want help with school or training? For example, starting or completing job training or getting a high school diploma, GED or equivalent.

Yes No
Source AHC Technical Expert Panel, 2016
No threshold The source defines no positive-screen rule for this item.
AHC-17 Physical Activity (1 of 2) choose one

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)?

0 0 1 1 2 2 3 3 4 4 5 5 6 6 7 7
Source Exercise Vital Sign — Coleman et al., Med Sci Sports Exerc, 2012
AHC-18 Physical Activity (2 of 2) choose one

On average, how many minutes did you usually spend exercising at this level on one of those days?

0 0 10 10 20 20 30 30 40 40 50 50 60 60 90 90 120 120 150 or greater 150
Scoring 1. Compute days × minutes = minutes of exercise per week. 2. Apply the age threshold: Under 6 — not assessable; Ages 6–17 — less than an average of 60 minutes per day indicates a need; Age 18+ — less than 150 minutes per week indicates a need.
Source Exercise Vital Sign — Coleman et al., Med Sci Sports Exerc, 2012
AHC-19 Substance Use (1 of 4) choose one

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.

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.

Never Once or Twice Monthly Weekly Daily or Almost Daily
Source NIH/NIAAA, Helping Patients Who Drink Too Much: A Clinician's Guide, 2005
No threshold The source defines no positive-screen rule for this item.
AHC-20 Substance Use (2 of 4) choose one

How many times in the past 12 months have you used tobacco products (like cigarettes, cigars, snuff, chew, electronic cigarettes)?

Never Once or Twice Monthly Weekly Daily or Almost Daily
Source NIH/NIAAA, 2005
No threshold The source defines no positive-screen rule for this item.
AHC-21 Substance Use (3 of 4) choose one

How many times in the past year have you used prescription drugs for non-medical reasons?

Never Once or Twice Monthly Weekly Daily or Almost Daily
Source NIH/NIAAA, 2005
No threshold The source defines no positive-screen rule for this item.
AHC-22 Substance Use (4 of 4) choose one

How many times in the past year have you used illegal drugs?

Never Once or Twice Monthly Weekly Daily or Almost Daily
Source NIH/NIAAA, 2005
No threshold The source defines no positive-screen rule for this item.

Items AHC-19 through AHC-22 may create 42 CFR Part 2 protected records depending on who administers them and where the responses are stored. Resolve this before these items are fielded.

AHC-23a Mental Health (1 of 2) scored scale

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

Little interest or pleasure in doing things?

Not at all 0 Several days 1 More than half the days 2 Nearly every day 3
Source PHQ-2 — Kroenke, Spitzer & Williams, Medical Care, 2003
AHC-23b Mental Health (2 of 2) scored scale

Feeling down, depressed, or hopeless?

Not at all 0 Several days 1 More than half the days 2 Nearly every day 3
Scoring Sum AHC-23a and AHC-23b. A total of 3 or more indicates a possible mental health need.
Source PHQ-2 — Kroenke, Spitzer & Williams, Medical Care, 2003

PHQ-2 is the first two items of PHQ-9 and does not include the suicidal ideation item. A defined escalation pathway must exist before this item is fielded.

AHC-24 Stress choose one

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?

Not at all A little bit Somewhat Quite a bit Very much
Source Elo, Leppänen & Jahkola, Scand J Work Environ Health, 2003
No threshold The source defines no positive-screen rule for this item.
AHC-25 Disabilities (1 of 2) choose one

Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?

Yes No
Applies to Age 5 and older
Source HHS/ASPE Data Collection Standards, 2011
No threshold The source defines no positive-screen rule for this item.
AHC-26 Disabilities (2 of 2) choose one

Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?

Yes No
Applies to Age 15 and older
Source HHS/ASPE Data Collection Standards, 2011
No threshold The source defines no positive-screen rule for this item.

Part 3 — Proposed local additions

Not part of AHC
LOCAL-01 Child Care Impact choose one

During the past 12 months, did you or anyone in the family have to quit a job, not take a job, or greatly change your job because of problems with child care for this child?

Yes positive No
Applies to Households with children
Note Benchmarkable against NSCH state and national estimates.
Source National Survey of Children's Health (federal survey wording; public domain)
LOCAL-02 Child Care Need choose one

Do you need child care for your child? If yes, would you like help finding it?

No, I don't need child care Yes, and I would like help finding it positive Yes, but I don't need help right now positive
Applies to Households with children
Note LOCAL-01 measures consequence; LOCAL-02 measures current demand. Both are needed for referral routing.
Source Adapted from WE CARE (Garg et al.)
LOCAL-03 Global Help Request choose one

Would you like help with any of the needs you told us about today?

Yes positive No
Note Separates "has a need" from "wants assistance now."
Source Adapted from AAFP EveryONE Project (item 11)
Transcribed from the CMS AHC HRSN Screening Tool. Questions and response options are reproduced verbatim; domain groupings and this layout are ours. Illustrative internal reference — not a fielded instrument.

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