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: ________________
City: ________________ State: ______________ Zip: ______________
Telephone: ____________________ Email: ________________________
Q1. Describe your relationship with your father, mother, and siblings?
Q2. What was the social standing of your family?
b) Very Good
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?
Q6. Did you have a strong support group of family and friends while growing up?
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?
Q10. Does your family practice social events?
Q11. Does your family visit social gatherings and events?
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