Social History Questionnaire
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Social History Questionnaire
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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.
What's included
- Tobacco, alcohol, and substance use screening tools
- Social determinants of health (SDOH) assessment
- Occupational history and hazard exposure documentation
- Exercise, diet, and lifestyle factor recording
- Intimate partner violence and safety screening
- Advance directive and healthcare proxy status
Who uses this template
- Primary care comprehensive health assessment
- Behavioral health intake and substance use screening
- Public health social determinants of health screening
- Preventive medicine lifestyle risk factor documentation
All form fields
14 fields across 2 pages. Customize any field after signing up.
How to use the Social History Questionnaire
Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Social History Questionnaire from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.
Setup steps
- 1Choose the template. Find the Social History Questionnaire in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 14 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
Is the Social History Questionnaire HIPAA compliant?
Yes. All Formisoft templates, including the Social History Questionnaire, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 14 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.
Does this template work on mobile devices?
Yes. The Social History Questionnaire is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
Sign up and start customizing the Social History Questionnaire for your practice. Set up in minutes.
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