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Table 3 Sample psychosocial screening tool for prenatal care

From: Screening for social determinants of health in clinical care: moving from the margins to the mainstream

Do you have any problems that prevent you from keeping your health care appointments? How many times have you moved in the past 12 months? Do you feel unsafe where you live? Do you or any members of your household go to bed hungry? In the past two months, have you used any form of tobacco? In the past two months, have you used drugs or alcohol (beer, wine or mixed drinks)? In the past year, has anyone hit you or tried to hurt you? How do you rate your current stress level—low or high? If you could change the timing of this pregnancy, would you want it to happen earlier, later, not at all or would you not change it?
  1. Adapted from reference [11]