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.
What is your living situation today?
Think about the place you live. Do you have problems with any of the following? CHOOSE ALL THAT APPLY
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.
Within the past 12 months, the food you bought just didn't last and you didn't have money to get more.
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?
In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home?
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?
How often does anyone, including family and friends, insult or talk down to you?
How often does anyone, including family and friends, threaten you with harm?
How often does anyone, including family and friends, scream or curse at you?
How hard is it for you to pay for the very basics like food, housing, medical care, and heating? Would you say it is:
Do you want help finding or keeping work or a job?
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?
How often do you feel lonely or isolated from those around you?
Do you speak a language other than English at home?
Do you want help with school or training? For example, starting or completing job training or getting a high school diploma, GED or equivalent.
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)?
On average, how many minutes did you usually spend exercising at this level on one of those days?
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.
How many times in the past 12 months have you used tobacco products (like cigarettes, cigars, snuff, chew, electronic cigarettes)?
How many times in the past year have you used prescription drugs for non-medical reasons?
How many times in the past year have you used illegal drugs?
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.
Over the past 2 weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things?
Feeling down, depressed, or hopeless?
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.
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?
Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?
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?
Do you need child care for your child? If yes, would you like help finding it?
Would you like help with any of the needs you told us about today?
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