Occupations

Describe:__________________________________________

1. Health Perception Health Management Pattern

_________________________________________________

Objective:

8. Habits of purchase drugs over counter? No__ Yes__

(Name/ Dosage/ Time per day/ Reason)

Subjective:

Describe:__________________________________________

1. How would you describe your usual health status? Good__

_________________________________________________

Fair__ Poor__ //

9. Have you followed the routine prescribed for you?

0-10__ Why marks deduction?

No__ Yes__

______________________________________

Why not? __________________________________________

2. Are you satisfied with your usual health status?

10. Did you think this prescribed routine was best for you?

Yes__ No__ Sources of

Yes__ No__ What would be better?

dissatisfaction:_______________________________

__________________________________________________

3. Tobaccos used? No__ Yes__ No. of packs per day____

4. Alcohol used? No__ Yes__
How much and what kind____________________
5. Street drug use? No__ Yes__ What and how much____
6. Any history of chronic disease? No__ Yes__
Describe:__________________________________________
__________________________________________________
7. Any history of chronic medication? No__ Yes__

11. Have you sough any health care assistance in the past year?
No__ Yes__ Why?
__________________________________________________
12. Do you have regular body check-up? No__ Yes__
Describe:__________________________________________
13. Do you do breast/testicular self-examination? No__ Yes__
How often: ________________________________________

14. Immunization history:

20. How would you rate living conditions at home?

Tetanus__ Pneumonia__ Influenza__ MMR__ Polio__

Excellent__ Good __ Fair__ Poor__

Hepatitis B__

Describe any problem areas:

15. Have you had any accidents/injuries/falls in the past year?

No__ Yes__ Describe:
__________________________________________________
16. Have you had any problems with cuts healing? No__ Yes__
Describe:__________________________________________
17. Have you had any vertigo/convulsion? No__ Yes__

_________________________________________________
21. Do you exercise on a regular basis? No__ Yes__
Types & frequency:
_______________________________________________
22. Do you have ay difficulty securing any of the following
services?

How often and When:

Grocery store No__ Yes__; Pharmacy No__ Yes__;

_____________________________________________

Health care facility No__ Yes__; Transportation No__ Yes__;

18. Do you have any suggestions or requests for improving your

Telephone (eg police, fire, ambulance) No__ Yes__;

health? No__ Yes__ Describe:

if any difficulties, note referral here:

_____________________________________________

_________________________________________________

19. Are you currently working? No__ Yes__ How would rate your

23. Do you know how to manage the disease?

working conditions? (e.g. safety, noise, space, heating,

_________________________________________________

cooling, water, ventilation)?

Do you know the reasons of getting the disease?

Excellent__ Good __ Fair__ Poor__

________________________________________________

Describe any problem areas:

__________________________________________________

24. What things are important to you while you are here? How can

7. Describe an average days food intake for you (meals and

we be helpful?

snacks):

__________________________________________________

__________________________________________________
__________________________________________________
8. Describe an average days liquid intake for you:____________

2. Nutritional-Metabolic Pattern

9. Have you taken any vitamins/supplement? _______________

Objective:

10. Describe food likes and dislikes:

Subjective:
1. Any weight gain in the last 6 months?
No__ Yes__ Amount ______________
2. Any weight loss in the last 6 months?
No__ Yes__ Amount _______________

__________________________________________________
__________________________________________________
11. Would you like to: Gain weight___ Lose weight___ Neither__
12. Any problems with:
A.

3. How would you describe your appetite?

Good__ Fair__ Poor__ Reason:

_________________________________
B.

__________________________________________________
4. Do you have any food allergy? No__ Yes__ Describe

C.

Swallowing: No__ Yes__ Describe

_____________________________

D.

__________________________________________________
6. How many times do you cook at home per week? __________

Vomiting: No__ Yes__ Describe

_______________________________

__________________________________________________
5. Do you have any dietary restrictions? No__ Yes__ Describe

Nausea: No__ Yes__ Describe

Chewing: No__ Yes__ Describe

_______________________________

E.

Indigestion: No__ Yes__ Describe

______________________________
13. Would you describe your lifestyle: Active___ Sedate___
14. Do you have any concerns with Breastfeeding?
No__ Yes__ Describe
_____________________________________________
15. Are you having any problems with Breastfeeding?
No__ Yes__ Describe
_____________________________________________