Social History Questionnaire Relationship Status Never MarriedMarriedSeparatedDivorcedWidowedSignificant Relationships Have you ever used any of the following? AlcoholSleeping PillsPCPMarijuanaDiet PillsAngel DustCocaineLaxativesEcstasyNicotineHeroin, CodeineCaffeineSpeed Medical History How do you view your health? ExcellentGoodFairPoor Social History Family Members (Mother, Father) Family Members (Stepmother, Stepfather) Family Members (Brothers and Sisters) Family Members (Spouse) Family Members (Children) Education Employment Military History Legal
