Medically Fit For Exams
Medically Fit For Exams

Full social history

  • Wash hands and introduce yourself
  • Check the patient’s name and DOB
  • Ask if it’s okay to have a chat with the patient about their background

 

  • Ask the patient how they are
  • Ask how they got to the clinic today
  • Ask where they live: house, bungalow, sheltered, residential
  • Ask who they live with
  • Ask if there are people around to help/visit
  • Ask if they have children/grandchildren
  • Ask how they get on at home:
    • Stairs
    • Washing/dressing
    • Cooking
    • Shopping
    • Medications (taking them and collecting them)
  • Ask about occupation/past occupation
  • Ask about smoking history
  • Ask about drinking history
    • CAGE screening
    • Concern about how much alcohol
    • Annoyed at other people commenting on amount of alcohol
    • Guilty about how much alcohol
    • Early morning drinking

 

Summary

  • Ask if the patient has any questions
  • Ask if you’ve missed anything
  • Summarise if appropriate
  • Thank the patient for their time
Full social history.docx
Microsoft Word document [13.5 KB]

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