Social history (medicine)

In medicine, a social history (abbreviated "SocHx")^[1] is a portion of the medical history (and thus the admission note) addressing familial, occupational, and recreational aspects of the patient's personal life that have the potential to be clinically significant.

Components

Components can include inquiries about:

• Substances
  • Alcohol
  • Tobacco (pack years)
  • illicit drugs
• occupation
• sexual behavior (increased risk of various infections among prostitutes, people who have sex with people for money, and males engaging in anal-receptive intercourse)
• prison (especially if tuberculosis needs to be ruled out)
• travel
• exercise
• diet
• Firearms in household (especially if children or persons with cognitive impairment are present)

Relation to history

CMS required history elements^[2]

Type of history	CC	HPI	ROS	Past, family, and/or social
Problem focused	Required	Brief	N/A	N/A
Expanded problem focused	Required	Brief	Problem pertinent	N/A
Detailed	Required	Extended	Extended	Pertinent
Comprehensive	Required	Extended	Complete	Complete

References

1. "Medscape.com". Archived from the original on January 1, 2004. Retrieved 2009-04-10.
2. "Evaluation and Management Services Guide" (PDF). www.cms.gov. December 2010. Archived from the original (PDF) on 2012-04-11. Retrieved 2011-02-27.