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
Employed current occupation(s): _________________________

Living arrangement
Alone
Family
Roommate
Significant other
Children (list sex/ages) __________

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

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
IUD, Diaphragm
Artificial Limbs
Other
No