Socioeconomic Status (SES) Questionnaire

The Socioeconomic status (SES) Questionnaire encompasses not just income but also educational attainment, financial security, and subjective perceptions of social status and social class. Socioeconomic status can encompass quality of life attributes as well as the opportunities and privileges afforded to people within society.

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Family History and Other General Information

Age

Parent/Guardian

Child

Gender

Parent/Guardian

Child

Ethnic Origin

Martial Status

How many people are currently living in your household, including yourself?

What is the primary language spoken at home?

Please describe the home where you live:

It is owned or being bought by you (or someone in the household)

It is rented for money by you (or someone in the household)

It is occupied without payment or money or rent

I live with friends

I live with famliy

I have no permanent residence

Education

What is the highest level of education you have completed?

Insurance

How do you pay for your health care and medical expenses?

Government Funding (Medicaid, Medicare, etc.)

Private Insurance

Self pay, out of pocket

Employment

Are you employed?

Who earns income to support your family?

How many hours each week do(es) the above person(s) work?

What best corresponds to the above person(s) current work situation?

Person 1

Person 2

Person 3

Do you have other resources to support your family?

What resources do you use?

Income

What is your total combined family income for the past 12 months, before taxes, from all sources, wages, public assistance/benefits, help from relatives, alimony, and so on?
If you don't know your exact income, please estimate.

Medical History

How would you describe your general health?

Please indicate whether you have ever had a significant problem with any of the symptoms or conditions listed below.

Chest pain or pressure

Chest pain with exertion

Heart Attack

Rapid/Irregular heartbeats

Fainting/Lightheadedness

Rheumatic fever

Calf pain with exercise

Varicose veins

Phlebitis

Stroke

High blood cholesterol

High blood triglycerides

High blood pressure

Diabetes

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