Homeless Individual Health Risk Assessment
Personal Information
Full Name
Age
Gender
Female
Male
Other
Prefer not to say
Contact (if available)
Living Situation
Current Living Situation
Shelter
Street/Outside
Vehicle
Staying with friends/family
Other
How long have you been homeless?
Health Information
Existing Medical Conditions
Current Medications (if any)
Allergies
Presenting Symptoms/Concerns
Mental Health & Substance Use
Mental Health History
Depression
Anxiety
PTSD
Other
Substance Use
Alcohol
Drugs
Tobacco
None
Other
Other Mental Health or Substance Use Concerns
Other Health Risks & Needs
Nutrition/Food Access
Access to Hygiene & Sanitation
Priority Health or Social Needs