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What do you do to stay healthy? Do you drink alcohol or use tobacco products?
Do you have regular check-ups with your physician and/or specialists (Pediatrician,Ob/Gyn, Cardiologist,
etc.)? Do you listen to and follow any suggestions made by yourhealth care providers?
Nutritional-Metabolic Pattern
Describe your
Family’stypical daily food intake? Do you consider your family healthy eaters?
Does anyone consider themselves over or under weight? Is there any unexplained weight gain or loss?
Elimination Pattern
Activity-Exercise Pattern.
What do you like to do in your spare time? What sports do you participate in?5
Sleep-Rest Pattern
Do you feel that you are generally well rested and able to perform your daily activities?
How well do you fall asleep? Stay asleep? Do you use any aids to help you sleep?
Does anyone have difficulty seeing? Do you have routine eye exams?
How do you learn best? Preference for visual or audio aids? Do you have difficultylearning?
Roles-Relationships Pattern
Who do you live with? Alone, family, others? What was the structure in which you grewup?
Do you belong to social groups? Do you interact with others outside of work or school?
Sexuality-Reproductive Pattern
Parents: How would you describe your sexual relationship? Satisfying? Changes?Problems?
Female: Describe menstruation cycle. Problems? Last menstrual period? Para? Gravida?
Who is most helpful in talking things over? Are the frequently available to you?
Values-Beliefs Pattern.
Describe your plans for the future. Do you generally get what you want from life?