Create Tools

  1. Create questionnaire
  2. Create prescription
  3. Create written directions

The Survey or Questionnaire

The "Hunger Vital Signs" as nationally recognized is a 2 question survey:

  1. Within the past 12 months we worried whether our food would run out before we got money to buy more.
  2. Within the past 12 months the food we bought just didn't last and we didn't have money to get more.

Positive answers are if the person answers sometimes or more frequently. Negative answer are if the person answers never.

Burke Pediatrics, LLC chose to use a more extensive tool (7 questions) as we were developing a practice focus on nutrition, hired a Pediatric dietician and began to offer nutritional services such as individual patient sessions dealing with clinical issues such as obesity and education group sessions for parents and adolescents on good nutrition practices.

Our survey, then not only served as a tool to identify patients who lived in "food insecure" households but also served as a data base to identify families with interest in nutrition and direct our nutritional education outreach efforts. This also allowed us literally to screen all patients without fear of humiliating anyone with a possible focus appearing to be on likely indigent families only. This turned out to be a good strategy as we learned many of our food insecure families (33%) were not medically indigent; they had commercial, employer sponsored health insurance. We also recognized that our families circumstances change frequently so we regularly re-survey our patients.

The Prescription

Below is a template that we at Burke Pediatrics, LLC created. Feel free to download the file and modify to insert your own practice logo and text.

Download prescription template

Written Directions

Below is a template we have placed on the back of our prescription. You can place appropriate language specific to your practice.

Keep and Present this prescription at "RX for Food" project sites where you can get a nutritious "Barbecue" meal and up to 100 pounds weekly of free food. For transportation if needed, call 703-978-6061. The website page, http://www· will provide access to nutrition education and details about consultation, counseling, and weight management information.