Social History. Smoking Status:
Social History. Include pertinent findings about use of tobacco products, alcohol, prescription and non-prescription drugs, etc.;
Social History. How would you describe your support system in the area? • What does a typical day look like for you? What do you enjoy doing? • Do you identify with any religious background or spiritual practice? • Children: ☐ Yes ☐ No Are you a new or expecting parent? ☐ Yes ☐ No Notes on children (i.e. custody, # of dependent children): • Have you had significant periods in which you have had experienced serious problems getting along with people in your life? Note: “Serious problem” means those that endangered the relationship. Also, a “problem” requires contact of some sort, either by telephone or in person In the past 30 days In the past year Parents (mother or father) ☐ ☐ ☐ ☐ Siblings ☐ ☐ ☐ ☐ Sexual partner/spouse ☐ ☐ ☐ ☐ Children ☐ ☐ ☐ ☐ Other significant family (specify) ☐ ☐ ☐ ☐ Close friends ☐ ☐ ☐ ☐ Neighbors ☐ ☐ ☐ ☐ Co-workers ☐ ☐ ☐ ☐ • Do you have a primary care physician? If so, who and when did you last see them? • When was the last time you saw a doctor/nurse? What was the purpose? How was the experience? • • Number of ER visits in the last year: • Hospital inpatient days in the last year: • Hospital admissions in the last year: • Notes: • Have you ever been a victim of a violent attack during homelessness? ☐ Y ☐ N • Have you ever had any serious head injury/trauma? (Did you lose consciousness? Were you hospitalized? Was surgery required?) • Do you currently have any pain or discomfort? Is it chronic or sporadic? • Are you prescribed any medications? ☐ Y ☐ N • Have you been prescribed medications while in jail/prison? ☐ Y ☐ N • How is your sleep? How many hours per day/night? • Do you have vision or dental concerns? • Do you have any of the following ongoing health issues and are you receiving care for this issue? Kidney disease or dialysis ☐ ☐ ☐ ☐ Liver disease or cirrhosis ☐ ☐ ☐ ☐ Heart disease or history of heart attack ☐ ☐ ☐ ☐ HIV+/AIDS ☐ ☐ ☐ ☐ Emphysema ☐ ☐ ☐ ☐ Diabetes ☐ ☐ ☐ ☐ Asthma ☐ ☐ ☐ ☐ Cancer ☐ ☐ ☐ ☐ Hepatitis C ☐ ☐ ☐ ☐ Tuberculosis ☐ ☐ ☐ ☐ Seizure disorder ☐ ☐ ☐ ☐ Stroke ☐ ☐ ☐ ☐ Other ☐ ☐ ☐ ☐ Other ☐ ☐ ☐ ☐ • Do you have any concerns about your mental health? (Onset? When did you first receive tx? Previous diagnoses? Most recent diagnosis?) • Has anyone ever told you that you have mental illness? • Overall, how would you describe your mood? • Have you ever been prescribed medication for mental health reasons? NAME: DOSE: PURPOSE: DURATION: PRESCRIBER: HELPFUL? ☐ Y ☐ N ☐ Y ☐ N ☐ Y ☐ N ☐ Y ☐ N • Do you ever have thoughts about hurting yourself? Abo...
Social History. What is your current living situation (who lives with you? Please include names and ages of children/parents): Are you experiencing any legal problems (problems types including DUI's, probation officer involvement, pending court dates, arrests, jail time): What do you do for work? What is your satisfaction level with your occupation? Please specify your level of education: What groups, religious affiliations, and supportive networks are you a part of? Please specify those of primary importance: Yes / No If yes, how much/ how often: Are you currently able to abstain for 72 hours? Nicotine Use: Yes / No If yes, how much/ how often: Are you currently able to abstain for 72 hours? Caffeine Use: Yes / No If yes, how much/ how often: Are you currently able to abstain for 72 hours? Yes / No If yes, how much/ how often/how are you ingesting: Are you currently able to abstain for 72 hours?
Social History. Do you currently smoke cigarettes? ❑ Yes ❑ No How many packs a day? _ ❑ Never smoked Age started? Have you quit smoking cigarettes? When? How many packs a day? _ _ (Congratulations !) Age started? _ Age stopped? Have you chewed tobacco? ❑ Yes ❑ No How many cans per day?_ ❑ Never Age started? _ ❑ Former Age stopped? ❑ Current Do you drink alcoholic beverages? ❑ Former ❑ Yes ❑ No Average drinks per week Have you used “street” drugs? ❑ Yes ❑ No Type Quantity: Age started: _ Age stopped: Have you ever taken steroids? ❑ Yes ❑ No When? _ Reason Family History: ❒ None Medical problems of parents/brothers/sisters, such as cancer, heart disease, arthritis, high blood pressure, diabetes, bleeding problems, trouble with anesthesia, alzheimers, stroke, mental illness:
Social History. Do you smoke: How many packs per day? How many years?
Social History. Include pertinent findings about use of tobacco products, alcohol, prescription/non-prescription drugs, etc. Comment on the effects of substance abuse on functioning. If there is no history of substance abuse, include a statement to that effect; and iv. Family History (if pertinent).
i. Other complaints and symptoms the DDDS claimant has experienced relative to the specific organ systems; and
ii. Pertinent negative findings considered in making differential diagnosis of current illness or in evaluating the severity of this or any other alleged impairment.
Social History. Please list family members and significant others: Name Relationship Age Name Relationship Age What is the nature of the relationship with your: Mother:
Social History. Do you use Tobacco? In the Past? If yes, when did you quit?
Social History. Xxxxx Xxxxx
