Social History Clause Samples

Social History. Include pertinent findings about use of tobacco products, alcohol, prescription and non-prescription drugs, etc.;

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. 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. 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 use Tobacco? In the Past? If yes, when did you quit?

Social History. Occupation:

Social History. Do you smoke: How many packs per day? How many years?

Social History. If YES, amount & type: If YES, how often: If YES, type & amount: If YES, type, age, by whom: ____________________________________ ____________________________________ ____________________________________ ____________________________________ Father: ____________________________________________________________________________ Mother: ____________________________________________________________________________ Siblings: ____________________________________________________________________________ Others: ____________________________________________________________________________ Name of Facility: Address: City/State/Zip: Phone: Fax: Patient Name: Address: DOB: SSN: o Complete Files o From / / - / / ¢ Clinical Notes ¢ Radiology Reports ¢ Other Please Specify ¢ Lab Results ¢ Medication Lists ¢ Immunization ¢ Hospitalization Summary Today's Date: / / Primary Care Doctor: Frisco, Texas 75033 Legal First Name Legal Last Name Suffix Gender Address Apt # City State Zip ( ) ( ) - - Primary Phone Cell Phone Social Security # / / Birth Date ¢Married ¢Single ¢Divorced ¢Widowed ¢Other Email Address (this will be used for appointment reminders and newsletters) Preferred Contact Method ¢Cell ¢Home ¢Email Check for portal access Race Ethnicity Preferred Language ( ) Employeer Name Employeer Phone Number

Social History. Marital Status Occupation Tattoos: ❑ Yes ❑ No Exercise? ❑ Yes ❑ No How Often? Substance/Alcohol Abuse? ❑ Yes ❑ No Type? Do you currently smoke? ❑ Yes ❑ No Packs/Day #/Years ❖ Have you ever smoked? ❑ Yes ❑ No ❖ How long since you last smoked? Do you drink alcoholic beverages? ❑ Yes ❑ No # per Week ❖ Do you have sexual concerns you want to discuss? ❑ Yes ❑ No