The Personal and Social History captures the patient's personality and interests, sources of support, coping style, strengths, and fears. It should include: occupation and the last year of schooling; home situation and significant others; sources of stress, both recent and long-term; important life experiences, such as military service, job history, financial situation, and retirement; leisure activities; religious affiliation and spiritual beliefs; and activities of daily living (ADLs). Baseline level of function is particularly important in older or disabled patients (see p.__for the ADLs frequently assessed in older patients). The Personal and Social History also conveys lifestyle habits that promote health or create risk such as exercise and diet, including frequency of exercise, usual daily food intake, dietary supplements or restrictions, and use of coffee, tea, and other caffeine-containing beverages and safety measures, including use of seat belts, bicycle helmets, sunblock, smoke detectors, and other devices related to specific hazards. You may want to include any alternative health care practices.
You will come to thread personal and social questions throughout the interview to make the patient feel more at ease.
Was this article helpful?