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Social History Vision Document
We need to give provision for documenting the below categories
as part of Social History
Marital Status
Smoking Status
Education
Employment/Occupation
Living arrangement
LIFESTYLE ISSUES like Smoking Status, Alcohol use, recreational
drugs use, exercise,
dietary issues, etc
See below for further details.
Marital Status
Annulled
Divorced
Domestic Partner
Interlocutory
Legally Separated
Married
Never Married
Polygamous
Widowed
Education
High School College
Professional School
Other
Employment/Occupation
Retired
Unemployed
Homemaker
Employedcurrent occupation(s): _________________________
Living arrangement
Alone
Family
Roommate
Significant other
Children (list sex/ages) __________
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Lifestyle/Self-Care Issues
Smoking Status
Current every day smoker, If yes, how many? #_____yrs.
______________ packs per day
Current some day smoker, If yes, how many? #_____yrs.
______________ packs per day
Former smoker, If yes, when did you quit? ______________ Never
smoker
Smoker, current status unknown
Unknown if ever smoked
Current heavy tobacco smoker, If yes, how many? #_____yrs.
__________ packs per day
Current light tobacco smoker, If yes, how many? #_____yrs.
___________ packs per day
Do you drink alcohol (beer, wine, liquor, etc)? Yes No, If yes,
how much?
Type_________ & _________ drinks per week
Do you drink caffeine beverages (caffeine, tea, soda, etc)? Yes
No, If yes, which?
________
Do you use recreational drugs? YES NO, If yes, which?
_____________________
Do you manage stress well?
Yes, If Yes, Major stresses in last 2 years
Money
Job
Marriage
Home Life
Children
Other stress
No
Not Sure
Need Help
Do you exercise regularly? Yes, If yes, Type _______, How many
times per day/week ____
No, If no, why? ______________________________________
Do you use seatbelts while driving? Yes No
Do you wear a helmet while riding a bike? Yes No
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Memories of your childhood
Mostly happy
Mostly painful
Normal
dont recall
Do You Find Your Life
Generally Unsatisfactory
Too Demanding
Boring
Satisfactory
Do you enjoy your job? Yes No, If No, why?
________________________________
Do you allow time to unwind and relax? Yes No, If No, why?
_______________
Do you sleep soundly? Yes No, If No, why?
_________________________________
Are you satisfied with your sex life? Yes No, If No, why?
__________________________
Are you satisfied with your social life? Yes No, If No, why?
_____________________
Are you satisfied with your spiritual life? Yes No, If No, why?
_______________
Is your diet healthy enough? Yes No Not Sure Need Help
Typical Breakfast ______________________________
Typical Lunch ______________________________
Typical dinner ______________________________
Typical snacks ______________________________
Are you disabled?
Yes, If yes, Devices Do You Use
None Eyeglasses
Contact Lens
Hearing Aid
Dentures
Brace (Neck, Back)
Pacemaker
