Family Social History Questionnaire

A family social history questionnaire contains information related to the family history in a social context. This type of questionnaire is normally used by psychiatrists and other medical personnel have to understand the background of a patient and the background of their family. It reveals information related to the social standing of the family and its impact on the individual in question.

Family Social History Questionnaire Sample

Name of the Individual: _______________________________________

Age: __________  Sex: ___________  Marital Status: _______________

Place of birth: __________________  Date of Birth: ________________

Address: ___________________________________________________

City: ________________ State: ______________  Zip: ______________

Telephone: ____________________  Email: ________________________

Q1. Describe your relationship with your father, mother, and siblings?

_____________________________________________________________

Q2. What was the social standing of your family?

a)   Excellent

b)   Very Good

c)   Good

d)   Average

e)   Poor

Q3. What type of school did you go to?

a)   Public schools

b)   Private schools

c)   Night schools

d)   Vocation schools

Q4. What type of family structure did you have when growing up?

a)   Patriarchic structure

b)   Matriarchic structure

c)   Joint family

d)   Nuclear family

Q5. In which environment did you grow up?

a)   Urban

b)   Suburban

c)   Rural

Q6. Did you have a strong support group of family and friends while growing up?

a)   Yes

b)   No

Q7. What is your current financial status or of your family?

____________________________________________________________________

Q8. Which of the following issues do you or your family face?

a)   Cultural issues

b)   Religious issues

c)   Race based issues

d)   Language issues

e)   Financial issues

f)    Education issues

Q9. Does your family practice social traditions?

a)   Yes

b)   No

Q10. Does your family practice social events?

a)   Yes

b)   No

Q11. Does your family visit social gatherings and events?

a)   Yes

b)   No

Category: Social Questionnaire