Gcu Week 5 Health Assessment Questionnaire

Week 5 Family Health Assessment Questionnaire

Values, Health Perception:

1) Are there any past medical histories such as surgery or chronic illness?

2) Do you use any substances such as alcohol, tobacco, or drugs?

3) Are you taking any prescribed medications?

Nutrition:

1) Do you follow any specific diet as prescribed by your physician or yourself?

2) Do you use vitamins or nutritional supplements such as Ensure?

3) Do you have any difficulties with chewing or swallowing?

Sleep/Rest:

1) How many hours of sleep do you get each night?

2) Do you have any problems with sleeping through the night?

3) Do you use medication to help you sleep?

Elimination:

1) How often do you have a bowel movement?

2) Do you have problems with constipation or diarrhea?

3) Are there any problems with urinating or stress incontinence?

Activity/Exercise:

1) Do you follow an exercise regime?

2) Are you able to do all ADL’s without help?

3) Do you feel that you are physically strong or weak?

Cognitive:

1) Do you have any problems with memory?

2) Do you have difficulties making decisions?

3) Do you have problems concentration?

Sensory - Perception:

1) Do you have any vision problems?

2) Do you have any hearing problems?

3) Do you have any numbness on any part of your body?

Self - Perception:

1) Do you often feel depressed or anxious?

2) Do you feel hopeless?

3) Do you take any anti-depressant medication?

Role Relationship:

1) Are you married or single?

2) Do you have any children?

3) Are you currently employed?

Sexuality:

1) Are you sexually active?

2) Do you have or have had any STD’s?

3) Do you use contraceptives?

Coping:

1) How do you handle stress?

2) Are you relaxed most of the time?

3) Do you self-medicate when you are stressed?