Pre-visit questionnaire: Social history

1. With whom do you live? (check all that apply)			2. You are presently (check one):
Alone Spouse or partner Child Other (specify):			Single/never married Married Divorced/separated Widowed Living with significant other
3. Which of the following best describes your residence? (check all that apply)			4. If living at a facility, please list the name and contact number of the person to contact if medical treatment is needed:
Single-family house Condo/apartment Board and care/assisted living Nursing home Continuing care retirement community Other (specify):			Name of facility: Name: Phone number:
5. Do you consider yourself to be:			6. How much school did you complete?
Heterosexual or straight Gay or lesbian Bisexual Prefer not to answer			Less than 8^th grade Some high school High school graduate Some college College graduate Graduate school
7. How many children do you have?			9. You are presently (check one):
			Retired/not working Working part-time Working full-time
8. Are you in regular contact with your children?
Yes	No
10. Do you have a religious affiliation?
Yes	No
10a. If yes, please state:
10b. If yes, do you actively practice?		Yes	No
11. List your principal occupation and any other significant past occupations:
1. 2. 3. 4. 5.
12. Please list name(s) and phone number(s) of those persons you would call if you were sick and needed help:
Name: Phone number: Relationship:			Name: Phone number: Relationship:
Name: Phone number: Relationship:			Name: Phone number: Relationship:
12a. Do we have your permission to speak to the person(s) listed above on your behalf?				Yes		No
13. Compared with other people your age, how would you describe your health?
Excellent	Good	Fair	Poor
14. Do you employ someone to provide health-related care or help you in your home?
Yes	No
14a. If yes, please list name(s) and contact information:
14b. If yes, please indicate the number of hours per day and days per week your paid helper is available to you.			Hours per day: Days per week:
14c. Is this sufficient to meet your needs?			Yes		No
15. Do you get help from family members or friends in your home?
Yes	No
15a. If yes, please indicate the number of hours per day and days per week your family members(s) or friend(s) are available to you.			Hours per day: Days per week:
15b. Is this sufficient to meet your needs?			Yes		No
16. Do you provide care for a family member?
Yes	No
17. Do you currently use a home health care agency?
Yes	No
17a. If yes, please list name(s) and contact information:
18. On any day in the past year, have you ever had:
More than 3 drinks containing alcohol?			Yes		No
18a. Think about your typical week:
On average, how many days a week do you drink alcohol?			Days per week:
On a typical drinking day, how many drinks do you have?			Drinks per day:
19. Has anyone ever been concerned about your drinking?
Yes	No
*20. Have you EVER* used tobacco products including cigarettes?**
Yes (skip to 21)	No (skip to 22)
21. Do you currently use tobacco products?
Yes	No
21a. If yes, what kind of tobacco products?
If cigarettes, how many packs per day?			¼	½	1	1½	2+
21b. If no, when did you quit?			Year:
For how many years did you smoke?			Number of years:
How many packs per day?			¼	½	1	1½	2+
22. Do you use marijuana?
Yes	No	Prefer not to answer
22a. If yes, for what purpose?			Medical		Recreational

Graphic 89011 Version 3.0

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Pre-visit questionnaire: Social history