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Prescribe Life Eligibility Questionnaire

U.S. Household Food Security Survey Module: Six-Item Short Form (USDA, 2012)

These questions are about the food eaten in your household in the last 12 months and whether you were able to afford the food you need. For these statements, please respond whether the statement was often true, sometimes true, or never true for (you/your household) in the last 12 months.
1. The food that (I/we) bought just didn’t last, and (I/we) didn’t have money to get more. Was that often, sometimes, or never true for (you/your household) in the last 12 months? *This question is required.
2. (I/we) couldn't afford to eat balanced meals. Was that often, sometimes, or never true for (you/your household) in the last 12 months? *This question is required.
3. In the last 12 months, since last (name of current month), did (you/you or other adults in your household) ever cut the size of your meals or skip meals because there wasn't enough money for food? *This question is required.
4. How often did this happen—almost every month, some months but not every month, or in only 1 or 2 months? *This question is required.
4. In the last 12 months, did you ever eat less than you felt you should because there wasn't enough money for food? *This question is required.
5. In the last 12 months, were you ever hungry but didn't eat because there wasn't enough money for food? *This question is required.
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