How would you rate your health ?
Good
When was the last time you had a check-up?
Last year
What is the most important thing you do to keep healthy ?
Stay away from liquor and cigarettes
Elimination
How often do you have a bowl movement ?
Once a week
Do you use laxatives?
Sometimes
Do you have any problems with bowl control?
No
Problems with bladder ?
No
Odor, color, frequency
No odor, yellow, normal
Excessive perspiration?
No
Activity
Exercise pattern? Type regularity ?
No exercise
Sufficient energy?
Lack energy
Leisure activity ?
Read
Values
Is religion important ?
Yes
Do you have future plans?
Open an ALF
What are some things you want from life?
Health, peace
Nutrition
Do you experience any difficulty eating?
No
How many meals do you have a day?
Two
Do you take any supplements?
None
Sleep
What is your sleeping routine ?
I don’t have one
How many hours do you get of sleep a night?
Depends
Do you need any aids?
No
Cognitive
Hearing difficulty? Aids ?
No/ no
Vision? Glasses?
Yes
Any changes in memory?
No
Self perception
How do you describe yourself ?
Hard worker, determined
Depressed ?
Sometimes
Anxiety?
Sometimes
Are you able to have control over yourself?
Yes
Relationship
Who do you live with?
My husband and kids
Do you have any family problems?
At times
How are things at work?
Ok
Sexual
Are you married single?
Married
So you have any children ?
Two girls
Do you use contraceptives?
Yes
Coping
Any crisis?
Not currently
Any opportunities?
Always opportunities
Taking any meds ?
None