Social History Questionnaire

The Social History Questionnaire captures the non-medical factors that significantly influence a patient's health outcomes and treatment adherence. It covers tobacco use (type, pack-years, cessation history), alcohol consumption (AUDIT-C screening), recreational drug use (current and past), caffeine intake, and vaping or e-cigarette use. Each substance section includes quantity, frequency, duration, and any prior treatment or cessation attempts.

Beyond substance use, the form addresses social determinants of health (SDOH) that are increasingly recognized as primary drivers of health disparities. It screens for food insecurity, housing instability, transportation barriers, financial stress, intimate partner violence, social isolation, and health literacy. These SDOH factors directly impact a patient's ability to follow treatment plans, attend appointments, and afford medications -- making them essential clinical data points.

The template also documents occupation and occupational hazard exposures, exercise habits (type, frequency, duration), dietary patterns and restrictions, marital status, caregiver responsibilities, education level, primary language, and advance directive status. It is used across primary care, behavioral health, preventive medicine, public health programs, and any clinical setting that takes a whole-person approach to patient care.