Social History Questionnaire


A social history questionnaire seeks to provide details about a person’s social history. This includes his or her age, gender, race, height, weight, current residential address and previous addresses. The questionnaire also covers details about the respondent’s schooling, family history, employment and medical history. It also covers any aspects of social or psychological services the respondent may have benefited from, and the reasons why they did.  The questionnaire seeks to gauge just how well an individual fits in the society. In events where the respondent is too young, emotionally or psychologically immature, the parent is required to act as the respondent on their behalf.

Name__________________________________________________________________

Date-of-Birth____________________ Sex___________ Social Security No. ________

Race____________________ Weight_______________ Height___________________

Eye color________________ Hair Color_____________ Glasses/Contact Glasses_____

Do you have any unique marks or tattoos on your body_______ If yes, specify________________________________________________________________

Home address__________________ City__________________ Zip code____________

How long have you been using the current address? ___________________________

List other people living with you and your relationship to them

____________________relationship___________

________________________________________

Education History

Schools attended___________________ graduation date____________

Were you offered any specialized academic attention__________ (if yes, please specify) ______________________________________________________

Were there any schooling problems such as disciplinary, attendance problems or suspension experienced during your years of schooling? ___________________

Family History

Where were you born? ____________________Where were you raised? ____________

Were you raised by your biological parents? ________ If not, state who______________

Did any of your parents remarry?_____________

How many siblings do you have? ____________ brothers_________ sisters_________

Are you in full time employment? ________ Part time employment? ______ Jobless?_____

Have you ever enlisted the services of a counselor, psychologists or psychiatrist? ____________________________________________________________________

____________________________________________________________________

Category: Social Questionnaire

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