Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Social History Questionnaire
Your information
Full Name *
Tobacco Use History
- Never used tobacco
- Previously used tobacco
- Currently use tobacco
- Prefer not to answer
Alcohol Use (AUDIT-C)
Recreational Drug Use
Occupation & Employer
Occupational Hazard Exposures
Exercise Habits
Additional details
Dietary Patterns & Restrictions
Living Situation
- Live alone
- Live with family or partner
- Shared housing
- Supported living
- Other
- Prefer not to answer
Food Insecurity Screening
Transportation Barriers
Intimate Partner Violence Screen
Marital Status
- Single
- Married
- Partnered
- Separated
- Divorced
- Widowed
- Prefer not to answer
Advance Directive Status
Social History Questionnaire template from formisoft.com. formisoft.com/intake-templates/social-history