What do you believe caused your illness?

CLIENT PROFILE What course do you predict your illness will take?
How do you believe your illness should be treated?
Biographical Data Do you have or anticipate any difficulties in caring for
What is our name? yourself or others
Tell me about your background. at home? If yes, explain.
When were you born?
What level of education have you completed? Health Management and Habits
Have you ever served in the military? Tell me what you do when you have a health problem.
Do you have a religious preference? Specify. When do you seek nursing or medical advice?
Where do you live? How often do you go for professional exams (dental, Pap
What form of transportation do you use to come here or smears, breast, blood pressure)?
go other places? What activities do you believe keep you healthy?
Where is the closest health care facility to you that you Contribute to illness?
would go to if ill or in Do you perform self-exams (blood pressure, breast,
an emergency? testicular)?
When were your last immunizations? Are they up to date?
Reason for Seeking Health Care and Current Understanding of Do you use alcohol, tobacco, drugs, caffeine? Describe
Health the amount and length of time used.
Explain your major reason for seeking health care. Are you exposed to pollutants or toxins? Describe.
What has the doctor told you regarding your health?
Do you understand your medical diagnosis? Explain. Compliance with the Prescribed Medications and Treatments
Have you been able to take your prescribed medications?
Treatments / Medications If not, what caused your inability to do so?
Describe the treatments and medications you have Have you been able to follow through with your
received. prescribed nursing and medical treatment (eg, diet, exercise)?
How has your illness been treated in the past? If not, what caused your inability to do so?
What is being planned for your treatment now?
Do you understand the purpose of your treatment? Nutritional – Metabolic Pattern
Have you been satisfied with past treatments? Explain.
What prescribed medications are you taking? Dietary and Fluid Intake
What over-the-counter medications are you taking? Describe the type and amount of food you eat at
Do you have any difficulties with these medications? breakfast, lunch, and supper on an average day.
How do they make you feel? Do you attempt to follow any certain type of diet?
What is the purpose of these medications? Explain.
What time do you usually eat your meals?
Past Illnesses / Hospitalizations Do you find it difficult to eat meals on time? Explain.
Tell me about any past illnesses / surgeries you have had? What type of snacks do you eat? How often?
Have you had other illnesses in the past? Specify. Do you take any vitamin supplements? Describe.
How were the past illnesses treated? Do you take herbal supplements? Describe.
Have you ever been in the hospital before? Where? For Do you consider your diet high in fats? Sugar? Salt?
what purpose? Do you find it difficult to tolerate certain foods? Specify.
How did you feel about past hospital stays? What kind of fluids do you usually drink? How much per
How can we help to improve this hospital stay for you? day?
Have you received any home health care? Explain. Do you have difficulty chewing or swallowing food?
How satisfied were you with this care? When was your last dental exam? What were the results?
Do you ever experience a sore throat, sore tongue, or a
Allergies sore gums? Describe.
Are you allergic to any drugs, foods, or other Do you ever experience nausea and vomiting? Describe.
environmental substances Do you ever experience abdominal pains? Describe.
(eg, Dust, molds, pllens, latex) Do you use antacids? How often? What kind?
Describe the reaction you have when exposed to the
allergen. Condition of Skin
What do you do for your allergies? Describe the condition of the skin.
Describe your bathing routine.
Developmental History Do you use sunscreens, lotions, oils? Describe.
How well and how quickly does your skin heal?
Subjective Data Do you have any lesions? Describe.
Do you have excessively oily and dry skin?
Describe any physical handicaps you have. Do you have any itching? What do you do for relief?
Tell me about your health and growth as a child.
Tell me about your accomplishments in life. Condition of Hair and Nails
What are your lifelong goals? Describe the condition of your hair and nails
Has your illnesses interfered with these goals? Do you use artificial nails? How long? How often? Do you
had problems with these nails?
Objective data Do you have excessively oily or dry hair?
Have you had difficulty with scalp itching or sores?
Does this client have obvious developmental lags that Do you use any special hair or scalp care products (i.e.
need further assessment? permanents, coloring, and straightness)?
Do this client’s illnesses interfere with the ability to Have you noticed any changes in your nails ? Color?
accomplish the necessary developmental, physical, Cracking? Shape? Lines?
psychosocial, and cognitive
tasks required at each age level for normal Metabolism
development? What would you consider to be your ideal weight?
Does this client have any physical, psychosocial, or Have you had any recent weight gain or losses? Describe.
cognitive developmental lags that aggravate his or her illness Have you used any measures to gain or lose weight?
or inhibit self- Describe.
care? Do you have any tolerance to heat or cold?
Have you noted any changes in your eating or drinking
Health Perception – Health Management Pattern habits? Explain.
Have you noticed any voice changes?
Client’s Perception of Health Have you had difficulty with nervousness?
Describe your health.
How would you rate you health on a scale of 1 to 10
(10 is excellent) now, 5 years ago, and 5 years
ahead?

Client’s Perception of Illness

Describe your illness or current health problem.
How has this affected your normal daily activities?
How do you feel your current daily activities have
affected your health? Elimination Pattern
Obstetric history
Bowel Habits How many times have you been pregnant?
Describe your bowel pattern. Have there been any recent Describe the outcomes of each of your pregnancy.
changes? If you have children, what are the age and sex of
How frequent are your bowel movements? each?
What is the color and consistency of your tools? Describe your feelings with each pregnancy.
Do you use laxatives? What kind? How often do you use Explain any health problems or concerns with each
them? pregnancy.
Do you use enemas? What kind? How often do you use
them? If pregnant now:
Do you use suppositories? How often and what kind? Was this planned or unexpected pregnancy?
Do you have any discomfort with your bowel movements? Describe your feelings about his pregnancy.
Describe. What changes in your lifestyle do you anticipate with
Have you ever had bowel surgery? What type? Ileostomy? this pregnancy?
Colostomy? Describe any difficulties or discomforts you have had
with this pregnancy.
Bladder Habits How can I help you meet your needs during this
Describe your urinary habits. pregnancy?
How frequently do you urinate (when and how many
times)? Male or female
What is the amount and color of your urine?
Do you have any of the following problems with Contraception
urinating? What do you or your partner do to prevent
Pain? pregnancy?
Blood in urine? How acceptable is this method to both of you?
Difficulty starting a stream? Do this means of birth control affect your enjoyment
Incontinence? of sexual relations?
Voiding frequently at night? Describe any discomfort or undesirable effects this
Voiding frequently during the day? method produces.
Bladder infections? Have you had any difficulty with fertility? Explain.
Have you ever had bladder surgery? Describe.
Have you ever had a urinary catheter? When and how Perception of Sexual Activities
long? Describe you sexual feelings. How comfortable are
you with your feelings of masculinity or femininity?
Describe your level of satisfaction from sexual
Activity – Exercise Pattern relationship(s) on scale of 1 to 10 (with 10 being very
satisfying)
Activities of Daily Living Explain any changes in your sexual relationship(s)
Describe you activities on a normal day (including that you would like to make.
hygiene activities, cooking activities, shopping, eating, house Describe any pain or discomfort you have during
and yard activities, intercourse.
other self-care activities) Have you (your partner) experienced any difficulty
How satisfied are you with these activities? achieving an orgasm or maintaining an erection? If so, how
Do you have any difficulties with any of these self-care has this
activities? Explain. affected your relationship?
Does anyone help you these activities? How?
Do you use any special devices to help you with these Concerns Related to Illness
activities? How has your illness affected your sexual
Does your current physical health affect any of these relationship?
activities (eg, dyspnea, shortness of breath, palpitations, How comfortable are you discussing sexual problems
chest pain, pain, with your partner?
stiffness, weakness)? Explain. For whom would you seek help for sexual concerns?

Leisure Activities Special Problems

Describe the leisure activities you enjoy. Do you have or have you ever had a sexually
Has your health affected your ability to enjoy leisure? transmitted disease? Describe.
Explain. What method do you use in contracting a sexually
Do you have time for leisure activities? transmitted disease?
Describe any habits you have. Describe any pain, discomfort, or burning you have
while voiding.
Exercise Routine Describe any charge or unusual odor you have from
Describe those activities that you believe give you your penis/vagina.
exercise.
How often are you able to do this type of exercise? History of Sexual Abuse
Has your health interfered with your exercise? Describe the time and place the incident occurred.
Explain the type of sexual contact that occurred.
Occupational Activities Describe the person who assaulted you.
Describe what you do to make a living. Identify any witness present.
How satisfied are you with this job? Describe your feelings about this incident.
Do you believe it has affected you health? If yes, how? Have you had any difficulty in sleeping, eating, or
How has your health affected your ability to work? working since the incident occurred?

Sexuality- Reproduction Pattern Sleep – Rest Pattern

Female Sleep Habits

Describe your unusual sleeping time and habits (ie,
Menstrual history reading, warm milk, medications, etc.) at home.
How old were you when you began menstruating? How long does it take you to fall asleep?
On what date did your last cycle begin? If you awaken, how long does it take you to fall asleep
How many days does your cycle normally last? again?
How many days elapse from t6he beginning of one Do you use anything to help you fall asleep (ie,
cycle until the beginning of another? medication, reading, eating)
Have you noticed any change in your menstrual How would you rate the quality of your sleep?
cycle?
Have you noticed any bleeding between your Special Problems
menstrual cycles? Do you ever experience difficulty with falling asleep?
Do you experience episodes of chilling, flushing, or Remaining asleep?
intolerance to temperature changes? Do you ever feel fatigued after a sleep period?
Describe any mood changes before, during, and after Has your current health altered your normal sleep habits?
your menstrual cycle. Explain.
What was the date of your last Pap smear? Results? Do you feel your sleep habits have contributed to your
current illness? Explain.
Are there any major problems now?
Sleep Aids Who is the person you feel closest to in your family?
What helps you fall asleep? Explain.
Medications? How is your family coping with your current state of
Reading? health?
Relaxation techniques?
Watching TV? Perception of Major Roles and Responsibilities at Work
Listening to music? Describe your occupation
What is your major responsibility at work?
Sensory-Perceptual Pattern How do you feel about the people you work with?
If you could, what would you change about your work?
Perception of Senses Are there any major problems you have at work? If yes,
Describe your ability to see, hear, taste, feel, and smell. explain.
Describe any difficulty you have with your vision, hearing,
ability to feel (i.e. touch, pain, heat, cold), taste (i.e. salty, Perception of Major Social Roles and Responsibilities
sweet, bitter, Who is the most important person in your life? Explain.
sour), or smell Describe your neighborhood and the community in which
you live.
Pain Assessment How do you feel about the people in your community?
Describe any pain you have now. Do you participate in any social groups or neighborhood
What brings it on? What relieves it? activities? If yes, describe.
When does it occur? How often? How long does it last? What do you see as your contributions to society?
What else do you feel when you have this pain? If you could, what would you change about your
Show me on this drawing on a scale of 1 to 10, with 10 community?
being the most severe pain.
(Have a child use an Oucher Scale, with faces Coping-Stress Tolerance Pattern
ranging from frowning to crying.)
How has your pain affected your activities of daily living? Perception of Stress and Problems in Life
Describe what you believe to be the most stressful
Special Aids situation in your life.
What devices (i.e. glasses, contact lenses, hearing aids) How has your illness affected the stress you feel? Or how
or methods do you use to help you with any of these do you feel stress has affected your illness?
problems? Has there been a personal loss or major change in your
Describe any medications you take to help you with these life over the last year? Explain.
problems. What has helped you to cope with this change or loss?

Cognitive Pattern Coping Methods and Support Systems

What do you usually do first when faced with a problem?
Ability to Understand What helps you to relieve stress and tension?
Explain what your doctor has told you about your health/ To whom do you usually turn when you have a problem or
Are you satisfied with your understanding of your illness feel under pressure?
and prescribed care? Explain. how do you usually deal with problems?
What is the best way for you to learn something new Do you use medications, drugs, or alcohol to help relieve
(read, watch, television, etc)? stress? Explain.

Ability to Communicate VALUE-BELIEF PATTERN

Can you tell me how you feel about your current state of
health? Values, Goals, and Philosophical Beliefs
Are you able to ask questions about your treatments, What is most important to you in life?
medications, and so forth? What do you hope to accomplish in your life?
Do you ever have difficulty expressing yourself or What is the major influencing factor that helps you make
explaining things to others? Explain. decisions?
What is your major source of hope and strength in life?
Ability to Remember
Are you able to remember recent events and events of Religious and Spiritual Beliefs
long ago? Explain. Do you have a religious affiliation?
Is this important to you?
Ability to Make Decisions Are there certain health practices or restrictions that are
Describe how you feel when faced with a decision. important to you to follow while you are ill or hospitalized?
What assists you in making decisions? Explain.
Do you find decisions making difficult, fairly easy, or Is there a significant person (eg. minister, priest) from
variable? Describe. your religious denomination whom you want to be contacted?
Would you like the hospital chaplain to visit?
Self–Perception – Self-Concept Pattern Are there certain practices (eg, prayer, reading scripture)
that are important to you?
Perception Identity Is a relationship with God an important part of your life?
Describe yourself. Explain.
Has your illness affected how you describe yourself? Describe any other sources of strength that are important
to you.
Perception of Abilities and Self-Worth How can I help you continue with this source of spiritual
What do you consider to be your strength? Weaknesses? strength while you are ill in the hospital?
How do you feel about yourself?
How does the family feel about you and your illness?

Body Image
How do you feel about your appearance?
Has this changed since your illness? Explain.
How do you feel about other people with disabilities?

Role-Relationship Pattern

Perception of Major Roles and Responsibilities in the Family

Describe your family.
Do you live with your family? Alone?
How does your family get along?
Who makes the major decisions in your family?
Who is the main financial supporter in your family?
How do you feel about your family?
What is your role in the family? Is this an important role?
What is your major responsibility in the family? How do
feel about this responsibility?
How does your family deal with problems?