Create Tools

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

The Survey or Questionnaire

We were unsure in our practice order patient's response would be to initiating the "Hunger Vital Signs" 2 question questionnaire. We decided to incorporate the 2 questions into a nutritional survey and simultaneously offered dietary education to our practice. We partnered with a pediatric dietitian who offered consultation in educational sessions.

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.

Below is the 7 question questionnaire that we developed incorporating the hunger vital sign questions, #2 and #7.

  1. I worry about my child/children's eating habits
  2. Within the past 12 months we worried whether our food would run out before we got money to buy more
  3. I would attend classes at Burke Pediatrics offices on preparing balanced meals
  4. I am concerned about my child/children being or becoming overweight
  5. I would like more information on preparing balanced meals and healthy family nutrition
  6. When school is closed, I become more concerned with my children's nutrition
  7. Within the past 12 months the food we bought just didn't last and we didn't have money to get more

Download English PDF Download Spanish PDF

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

We developed a single prescription which is seen throughout the website. You can use a standard office pharmacy prescription and just right "food" on it and sign.

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.


Transportation can be provided to Medicaid members under EPSDT. In Northern Virginia, Medicaid managed care HMOs either provided transportation or reimbursed members upon request.