Social History Form






    Please select the box if the answer is 'Yes' to the question.

    Do you live alone?

    Do you have a stable housing situation?

    Do you have children?

    Do you have child custody issues?

    Do you drink alcohol?

    Do you drink caffeinated beverages?

    Do you take non-prescribed drugs?

    Are you employed?

    Are you disabled?

    Do you smoke cigarettes?

    Do you vape?

    Do you have unresolved legal issues?

    Are you on probation?

    Do you have adequate food?

    Do you have transportation?

    Are you under more stress than normal?