Example of social history report

Personal Social History

When writing the social history document, complete the template provided. Please complete all the sections noted in the template as if you were filling out a form as part of a job. Though this is supposed to be an "interview", all of the information can be made up. Attached is a sample of how it should look, the instructions, and the templet that should be used.

Social History
Identifying Information
Date: January 17, 2015

Name: John Smith

Date of birth: 8/17/1974

SS#: 123-45-6789

Insurance provider: Blue Cross/Blue Shield

Marital status: Married

Number of children: None

Address: 14 West Elm Street, Columbia, MO 65203

Telephone number: 573-456-1234

Age: 31

Race: Caucasian

Height: 5’ 11”

Weight: 185

Eye color: Brown

Hair color: Blond

Unusual markings (scars, birthmarks, tattoos): Small scar over left eye; large scars on right shin, left elbow, right forearm, and left calf; full-sleeve tattoos on both arms; tattoos covering chest and back; tattoos on both lower legs.

Allergies: Penicillin, cat dander

Current medications: None prescribed; OTC painkillers

Current medical problems: Client is experiencing back pain due to multiple fractures of the spine.

Present Problems (immediate presenting problems)
John's states his back pain is causing him difficulties on the job at the Sub Shop. He cannot stand for long periods of time as his job requires. John states that his boss is not supportive of moving him to another position that does not require standing. John is seeking another job that will accommodate his back problems.

Previous Problems (past issues or concerns that could affect the client’s functioning)
John was a competitive skateboarder. He states that he has experienced numerous skateboarding accidents dating from childhood. Most of the accidents were relatively minor, according to John, resulting in some broken bones and stitches. As a competitive skateboarder, John participated in the X Games for several years. In his last year of competition six years ago, he suffered an accident during the Big Air preliminary event. John was airborne when he lost control of his skateboard and fell to the concrete surface. He landed on his back, causing multiple fractures and a concussion. John states he has had multiple back surgeries, but none have relieved the back pain. John states he is fortunate to be able to walk. His previous doctor told him medication and continued surgeries would be his only relief from the back pain. He states he has had no residual effects from the concussion. Additionally, John states that he was a recreational drug user in his teens and early twenties. He states he has not used any drugs recreationally since his accident; however, he does consume alcoholic beverages, and he is a smoker. John states that he had a DWI a few years ago, and as a result his car insurance is so expensive he can't afford to pay the premiums. He doesn't drive at present.

Family History
Spouse (click the “+” button in the lower right to repeat this field as needed) Name: SS#: 123-45-6789 Address: Phone: DOB: Marital status: Employment: Education level: Court record: Drug/alcohol issues: Mental health: Physical health:

Parents/StepParents (click the “+” button in the lower right to repeat this field as needed) Name: Parent type: SS#: 123-45-6789 Address: Phone: DOB: Marital status: Employment: Education level: Court record: Drug/alcohol issues: Mental health: Physical health: Parents/StepParents (click the “+” button in the lower right to repeat this field as needed) Name: Parent type: SS#: 123-45-6789 Address: Phone: DOB: Marital status: Employment: Education level: Court record: Drug/alcohol issues: Mental health: Physical health:

Siblings (click the “+” button in the lower right to repeat this field as needed) Name: Type: Gender: DOB:

Sibling Interaction
John states that his interaction with Jennifer is positive overall. Although she did not agree with his competitive skateboarding career, John states that they bonded during their father's illness and subsequent death. Jennifer lives in Jefferson City, MO. John states they see each other at least twice a month as well as family events and holidays.

Other Close Relatives (click the “+” button in the lower right to repeat this field as needed) Type of Relative: Name: Other Close Relatives (click the “+” button in the lower right to repeat this field as needed) Type of Relative: Name: Other Close Relatives (click the “+” button in the lower right to repeat this field as needed) Type of Relative: Name:

Family Interaction
(Describe family dynamics/relationships, current issues, financial resources, needs, risks, etc.)

John describes his current relationship with his mother and sister as close. They see each other frequently for family get-togethers, events, and holidays. He says his mother was terrified about him skateboarding competitively, and he feels guilty because of his accident. His family rallied behind him after his accident and then rallied together during his father's illness and after his death. His mother has helped him financially due to medical bills resulting from his surgeries. Miriam provides health insurance through her job, but the out-of-pocket costs are still significant. There are still outstanding hospital and physical therapy bills.

Home and Neighborhood
(Describe type of home, adequacy of space, housekeeping standards, hazardous conditions, neighborhood description, etc.)

The case manager visited John's home on January 8, 2015. John and Miriam rent a unit in a duplex near downtown Columbia in a neighborhood primarily of rental properties. Their unit has two bedrooms and one bathroom. The unit was clean and appeared generally well-maintained. It appears to have adequate space for two adults. John says his landlord isn't always responsive, but things usually get fixed eventually. No hazards were evident at the time of the home visit.

Client’s Development
Early Developmental History
(Describe any problems during client’s mother’s pregnancy or delivery of client, planned/unplanned pregnancy, parental alcohol and drug use during pregnancy, developmental milestones, serious illnesses or accidents, diagnoses of ADHD or other.)

Rose Smith reported that her pregnancy with John was planned and was normal; however, John was a breech birth, which required a Cesearean section. She said that she did not use alcohol or drugs during her pregnancy with John, but she smoked occasionally. According to Mrs. Smith, John met most of his developmental milestones on time with the exception of walking. She states that he continued to crawl until he was 16 months old, which caused the pediatrician to express concern. John did walk after 16 months with parental intervention. John had no serious accidents or illnesses during his early developmental years. He had no developmental diagnoses.

Peer Interaction
(Describe relationships with peers, ages of friends, activities with friends, does or does not have friends.)

John states that he has numerous friends within the skateboarding community. He also keeps up with a lot of his friends from high school and college. Most of his friends range in age from 26-35. He says he is friendly with most of his coworkers and considers some of them close friends.

Education
(Last school attended, grade level, major school problems, accelerated/remedial/special education, truancy history.)

John graduated from Hickman High School and attended some college at the University of Missouri before dropping out to pursue competitive skateboarding. He states that in high school he took the expected coursework for graduation. No accelerated/remedial/special education classes were necessary, according to John. He states that he was an average student in high school. He skipped classes a few times and had some detention, but he states he didn't have significant behavioral issues in high school. At the University of Missouri, John states he began as a business major but wasn't interested in his classes. He began cutting class and wound up on academic probation after his freshman year. He dropped out after his first semester in his sophomore year.

Employment
(Current employment, brief summary of past employment, terminations, promotions, problems on the job.)

John states he has been employed at the Sub Shop in downtown Columbia for two years. He makes sandwiches and cashiers. Prior to the Sub Shop, John worked at Atomic Tattoos for two years; however, the tattoo shop closed, and he hasn't been able to find another job in tattooing. He worked at Sparky's Ice Cream before Atomic Tattoos. He also worked at Lakota Coffee as a bean roaster, and at Booche's as a burger cook and bartender. John states he has never been fired from a job, and he has never been promoted. At the Sub Shop, he must stand on his feet while making sandwiches and cashiering, which aggravates his back. His boss will not allow him to sit while he works.

Psychological
(Current and past psychological exams, including name of examiner, location of testing, and test dates.)

N/A

Agency Contacts and Sources of Information (List all other service providers and contact people. Click the “+” button in the lower right to repeat this field as needed.) Name: Relationship to client: Agency name: Address: Phone:

Preparer Information
Social history prepared by: Andrew Jones, Case Manager