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Routine IT maintenance on Wednesday, June 19 will cause service interruptions between midnight and 6:00am affecting the YourHealthNS app and on-line appointment booking including COVID-19 testing, blood collection, X-Ray, EKG and the Need a Family Practice Registry.  We apologize for any inconvenience.

Continuing Care Social History Template

Sharing What Matters with your Care Providers

When your care team knows as much as they can about you, they are able to provide the best possible care. One way you can help them get to know you is by filling out a Social History and sharing it with them.

Please consider filling out this form and sharing it with your care team. (Or you can ask us to give it to them for you.) This might include your home support agency or long-term care home. You can fill out as much or as little as you want and decide who you want to give it to. It is voluntary and choosing to fill one out or not has no impact to your access to Continuing Care services.

Contact

If you have any questions about this form, please talk to your Nova Scotia Health Care Coordinator or call us at 1-800-225-7225.

Social history template

Guide to filling out the form

Family (Related or Chosen) History:

  • This may be family by birth or by choice. Not all people have close ties to their related family. Chosen family might include unrelated individuals chosen to replace family (e.g. LGBTQ2SA+ community members, friends, etc.).
  • Place of birth? Raised (e.g. town, city, details about childhood home, etc.)?
  • Special pet(s)? Type? Name(s) (e.g. ‘Ginger’ Golden Retriever, ‘Puddles’ family cat, etc.)?
  • Places of Residence (e.g. towns/cities client has lived in throughout lifetime)

Relationship History:

  • Married/Common Law/Domestic Partnership? (name of spouse/significant other, date of wedding/ceremony/anniversary); Divorced/Single/Widowed (date)
  • Children? Name(s) and current place of residence?
  • Grandchild? Name(s) and current place of residence?


Life Work

  • Education/Certificates/Courses (e.g. diplomas, degrees, speciality training, etc.)
  • Share life work/occupation (e.g. stay at home parent, factory worker; shift worker, nurse, teacher, labour worker, etc.)
  • Community Involvement/Volunteer Work (e.g. Lions Club, Ladies Auxiliary, hospital volunteer, etc.)?
  • Wartime Experience? (If so, does client enjoy discussing military experience?)
  • If the individual is pediatric, include information about school such as favourite subjects, teachers, friends, etc. in the Additional Information section.


Spirituality or Religion:

  • Include any religious affiliation(s) and/or beliefs.
  • Has religion or spirituality played a role in the person’s life? (What provides a sense of purpose, meaning or source of energy? What do they value?
  • Important traditions? Specific holiday celebrations? Key generational practices? Daily rituals, readings, meditation, etc.?


Personality:

  • Dominant personality qualities? What words describe client best (e.g. easy going, worrier, family focused, humorous, etc.)?
  • Has personality changed over time/since illness? Discuss potential changes (e.g. private, gruff, impatient, nervous, etc.).


Significant Life Events:

  • Accomplishments/Achievements (e.g. achievements the person is most proud of)
  • Major Life Events/Milestones (e.g. marriage, birth of children, retirement, sporting accomplishment, trips/travel, etc.)
  • Dates of significance; (e.g. November 14, 1965 wedding anniversary, etc.).


Significant Low Point(s)/Trauma(s) in Life:

  •  Are there negative events that may evoke a negative emotional response? It is not necessary to include details of this event, but instead provide key messaging associated with any low point/life trauma (e.g. loss of loved one, financial instability, accident(s), health, etc.).
  • What might trigger unpleasant experiences/memories (e.g. people in uniform, dates/holidays, sounds, etc.)?
     

Coping Strategies & Items of Comfort/Joy:

  • How has client coped with stressful situations in life (e.g. journaling, painting, pacing/walking, music, etc.)?
  • Validation phrases? (e.g. “The children are OK”, “I am hear with you”, “Everything will be alright”, etc.).
  • What brings client pleasure or provides comfort/joy/inspiration (e.g. people, specific items, conversation topics, places, etc.)?


Cultural and/or Ethnic Traditions:

  • Are there cultural and/or ethnic traditions, holidays or preferences that are important and care partners should be aware of?

Favourite Hobbies, Activities, & Pastimes:

  • Hobbies, leisure activities, and/or interests that could assist with tailoring recreation programing or simply facilitate conversation (e.g. tennis, gardening, reading, nature/outdoors, music, hockey, hunting, shopping etc.)


Food Preferences:

  • Unique and/or special dietary preferences (e.g. vegan, vegetarian, gluten free, etc.).
     
  • Mealtime Preferences (e.g. prefers coffee prior to breakfast; one item served at a time; likes to eat alone/with others, etc.)


Daily Routine:

  • Typical time waking up time.
  • Morning Routine (e.g. coffee, toast and jam for breakfast, read daily paper, watch the news, etc.)
  • Bathing Routine (e.g. Shower? Bath? Sponge bath? Time of day? How many times a week?)
  • Daily Activities: activities that typically occupy day such as, walking, gardening, reading, home making tasks, etc.
  • Nighttime routine: evening activities to unwind, tasks prior to going to bed, nighttime snacks, etc.


Additional Information:

  • Provide any other information or tips that will help a care partner know client better and/or important information not captured in the previous categories.
     

Printer friendly version of the client guide to completing the social history template

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