Adult Social History Form Please fill out Online or Download and bring in Date (required) Patient's Legal Name (required) Patient's Preferred Name Email (required) Occupation Employer Relationship Status Name of Spouse/Partner Occupation of Spouse/Partner Family History Date Of Birth (required) Place Of Birth Primary city (or cities) of residence during childhood and adolescence Natural father's name Is he living? YesNo His place of employment Please describe your father. Please describe your relationship with your father. Natural mothers's name Is she living? YesNo Her place of employment Please describe your mother. Please describe your relationship with your mother. How were you impacted by your family of origin? List Any step-parents and their relationship to you. List your brothers, sisters and yourself, from oldest to youngest (include ages): Interpersonal History Please list your partners/spouses and your age when you were in the relationships: Overall, how would you describe your relationship with your current partner/spouse: List any children from oldest to youngest. Include their ages. Educational History Last grade completed: Where did you attend school: What were your normal grades in school: If you attended college, what did you major in? Did you do well academically? If you did not attend college, what did you do after high school? Occupational History When did you begin working and what type of jobs have you held. How long have you worked at your present job? Are you satisfied with your present job? yesno If not, what is the cause of your dissatisfaction? Are you a veteran?yesno If so, what branch of service? Date of discharge were you involved in combat?yesno Socio-Cultural History How would you rate the financial status of your childhood home? Were you raised in an: UrbanSuburbanRural Did you have a strong support group of friends growing up? YesNo How would you describe your current financial status? Is your present home: UrbanSuburbanRural What role does religion play in your family of origin? What is your religious preference? Are you active in your religion? YesNo To which racial or ethnic group do you primarily identify? Legal History Have you been convicted of any criminal offense? YesNo If yes, please describe. Are you currently involved with any legal issue? YesNo If yes, what? Have you been a victim of a crime? YesNo If yes, please describe. Substance Abuse History Have any of your family members had problems with alcohol and/or drug abuse? YesNo Please describe who, their relationship to you, and the substances they abused. Please describe your alcohol and/or drug use, past and present. Specify frequency and type of substance used. Have you ever received treatment for substance abuse? YesNo If so, when and where? Sexual History Have you ever engaged in sexual intercourse? YesNo If yes, at what age did you first engage in sexual intercourse? How satisfied are you with the quality of your current sexual activity? How do you identify your sexual orientation? How do you identify yourself in terms of gender identity? What are your preferred pronouns? Do you have any concerns related to your gender identity of your sexual orientation? YesNo If so, please describe. Trauma History As a child, were you abused? SexuallyPhysicallyEmotionallyMedically If yes, by whom? As an adult, have you been abused? SexuallyPhysicallyEmotionallyMedically If yes, by whom? Have you been impacted by: DeathDivorceSeparationOther Trauma If yes, please describe.