Certified Medical Assistant (CMA AAMA)Clinical Workflow and Patient IntakeMedium
During intake, a patient reports smoking one pack of cigarettes per day for the past 15 years and drinking alcohol socially on weekends. This information belongs in which section of the patient history?
- AFamily history
- BSocial history
- CHistory of present illness
- DReview of systems
Show answer & explanationAnswer & explanation
Correct answer: B. Social history
Social history includes lifestyle factors such as tobacco use, alcohol consumption, occupation, and living situation. Family history covers relatives' medical conditions, and review of systems is a systematic inquiry about body systems.
Why the other options are wrong
- A. Family history documents illnesses in blood relatives, not the patient's own habits.
- C. History of present illness describes details of the current complaint, not lifestyle habits.
- D. Review of systems is an organized checklist of symptoms by body system.
Social History
The section of patient history that documents lifestyle factors such as tobacco, alcohol, and drug use, occupation, exercise, and living situation.
- Includes smoking pack-years and alcohol use
- Distinct from family (genetic relatives') history
- Helps assess risk factors for disease
Memory trick: Social = lifestyle choices, like smoking and drinking on a Saturday night.