Client: Personal, Social, and Family Information

Name ___________________________________________________________________________________________________________________

Date of birth ______________________________________________________________________________________________________________

1. Today’s date _________________ 2. Age ___________________________________________________________________________________

3. Gender: M or F. Is your answer to question number 3 based on a transgender sexual change? If no sexual change has taken place, skip questions 4 and 5.

4. Date of procedure ___________ 5. Type of procedure ________________________________________________________________________

Medications prescribed ___________________________________________________________________________________________________

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Sexual orientation: heterosexual ____________________ gay/lesbian ______________ other ________________________________________

Proficient in speaking English YES NO

Proficient in reading English YES NO

Ability to read lips YES NO

Preferred spoken language ________________________________________________________________________________________________

Most comfortable language when speaking __________________________________________________________________________________

Most comfortable language when reading ____________________________________________________________________________________

Preferred greeting Mr. Mrs. Ms. First name ___________________________________________________________________________________

Type of nonverbal communication used _____________________________________________________________________________________

Eye contact _____________________________________________________________________________________________________________

Need of interpreter _______________________________________________________________________________________________________

Relation to interpreter _____________________________________________________________________________________________________

Quiet/use of silence ______________________________________________________________________________________________________

Use and definition of time __________________________________________________________________________________________________

Use of any common signs (okay, pain, clapping) ______________________________________________________________________________

Use of comfort space ______________________________________________________________________________________________________

Tactile use _______________________________________________________________________________________________________________

Use of cultural jargon or slang that may affect evaluation

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Perception of pain ________________________________________________________________________________________________________

Cultural ________________________________ Ethnicity _______________________________________________________________________

Family role and function ____________________________________________________________________________________________________

Work ___________________________________________________________________________________________________________________

Leisure activities _________________________________________________________________________________________________________

Friends _____________________ Others _____________________________________________________________________________________

Country of origin _________________________________________________________________________________________________________

Country of birth __________________________________________________________________________________________________________

Years in the United States __________________________________________________________________________________________________

Did you grow up in a city ______________ town _________ suburb _________________ rural ________________________________________

Ethnicity ________________________________________________________________________________________________________________

Major support group _______________________________________________________________________________________________________

Dominant members of the family ____________________________________________________________________________________________

Decision makers for the family ______________________________________________________________________________________________

Previous work history _____________________________________________________________________________________________________

Present work history _______________________________________________________________________________________________________

Education _______________________________________________________________________________________________________________

Describe importance of religion ____________________________________________________________________________________________

Religious beliefs/practices __________________________________________________________________________________________________

Religious association _____________________________________________________________________________________________________

Cultural/religious practices/restrictions _____________________________________________________________________________________

Meaning and use of religious symbols _______________________________________________________________________________________

Interaction with family/significant other—describe _____________________________________________________________________________

________________________________________________________________________________________________________________________

Role of father _________________________ Role of mother _____________________________________________________________________

Role of elder sibling/siblings _______________________________________________________________________________________________

Grandparents’ role _______________________________________________________________________________________________________

Number of dependents ____________________________________________________________________________________________________

Children/grandchildren ____________________________________________________________________________________________________

Are there any with physical limitations (deaf, mute, or blind)? Yes _________________ No __________________________________________

If you answered yes to the above, please identify what type ____________________________________________________________________

Means of communication __________________________________________________________________________________________________

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Expectation from this visit _________________________________________________________________________________________________

Food preferences ________________________________________________________________________________________________________

Beliefs on health promotion _________________________________________________________________________________________________

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Family history ____________________________________________________________________________________________________________

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Skin color/hair structure ___________________________________________________________________________________________________

Reason for Visit

Chief complaint __________________________________________________________________________________________________________

Perceived cause __________________________________________________________________________________________________________

Reasons for cause ________________________________________________________________________________________________________

Symptoms of illness _______________________________________________________________________________________________________

________________________________________________________________________________________________________________________

Onset and severity (pain scale) ______________________________________________________________________________________________

Effects of illness on ADL __________________________________________________________________________________________________

Fear of the unknown about illness ___________________________________________________________________________________________

Treatment expectations and results __________________________________________________________________________________________

Beliefs/practices about illness ______________________________________________________________________________________________

Health promotion beliefs and practice _______________________________________________________________________________________

Types of healing practices _________________________________________________________________________________________________

Client’s appearance ______________________________________________________________________________________________________

Common diseases and disorders ____________________________________________________________________________________________

Beliefs and practices regarding traumatic events _______________________________________________________________________________

Beliefs and practices for preventive health ____________________________________________________________________________________

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Surgical history __________________________________________________________________________________________________________

Other medical history ____________________________________________________________________________________________________

Any additional information that may improve client care _______________________________________________________________________

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ADL, activities of daily living.