Functional Health Pattern Sleep Rest 1.What is your usual pattern of sleep?

Do you have a normal sleep wake pattern? 2.Do you take any aids to assist you to sleep? 3.Do you feel rested and relaxed when you are awake? 4.Do you have any bedtime routines/rituals that you follow prior to sleep? 5.How many hours of sleep do you get every night? 6.Do you have difficulty falling asleep? Do you wake up in the middle of the night? 7.Do you wake up early or sleep in? What time do you usually get up? 8.What is your activity level during the day? Do you nap during the day? 9.Do you have difficulty staying awake during your normal daily activities? 10.Do you think that the medications you're on affect your ability to sleep> 11.Do you consistently have unusual dreams or nightmares? 12.Do you walk or talk in your sleep? 13.Are your legs uncomfortable, painful, or restless when lying down? 14.Do you have difficulty controlling your bladder at night? 15.Do you sleep in a bed or a recliner? 16.What a your caffeine intake? What are your eating habits in the evening? 17.Do you snore at night, suffer with memory loss, speech pattern slurring, lack of coordination, or difficulty concentrating? On a CPAP machine at rest? 18.Do you have pain that affects your ability to sleep? 19.Do you smoke? 20 Do you have lifestyle disruptions that affect your sleep? Functional Health Pattern Self Perception-Self Concept 1.How would you describe yourself? 2.Does your illness have any effect on your self image? 3. What methods do you use to keep your spirits up and positive? 4 How will being in this hospital or facility affect your life? 5.How would you describe your support systems? 6.Who relies on you? 7.Where do you go for moral support? 8.What do you do to take care of yourself? 9.How do you feel about being ill and being in this facility? 10.Do you have anxiety and how does it affect you? 11.Do you have anxiety disorders? Do you use psychotropic drugs, alcohol, or street drugs? 12.After talking to the patient how do they seem to perceive themselves? 13.Is there anything unusual about the patient's appearance? 14.Does the patient seem comfortable with their description/perception of self?

Functional Health Pattern Coping-Stress Pattern 1.How would you describe your state of being? Tense a io( of time, angry, calm, quiet, easily frustrated, etc.? 2.How do you usually cope with stressful situations? 3.Are there any other ways that you can relieve your stress and tension? 4.Do you use medications, drugs or alcohol to manage your stress or coping? 5.Do you have someone to confide in and to share your concerns with? 6.Have you experienced any recent life-style changes? 7.What methods do you incorporate in your life when solving problems?

8 .H o w w o u ld y o u c h a ra cteriz e th e le v e l o f s tre ss in y o u r life o v e r th e p at y e ar? 9 .D o y o u ta lk w ith y o u r sig n ifica n t o th e rs ab o u t p ro b le m s a n d co n c ern s ?

10.Who is your main supporter? 11.Are you aware of any stress relieving techniques? (Muscle relaxation, diaphragmatic breathing, progressive relaxation, visualization, etc.) 12.Have you had any treatment for emotional distress? Functional Health Pattern Role Relationship 1.Who are the members of your household? Live alone? Family structure? 2.How would you characterize the strengths of your marriage? 3.Do you have difficult family problems? 4.Is your family dependent on you? How are they managing during this hospitalization? 5.What is your family and significant others feeling about this illness? 6.What arc the ages of your children and where do they live? 7.Do you have problems with managing or handling your children? 8.When someone is ill, how does your family offer support? 9.Do you have problems snaring your problems and concerns with others? 10.Do you have concerns that this illness will affect your ability to perform your occupation? 11.Do you belong to social groups or have close friends? 12.Do you ever feel isolated or lonely? 13.Do you feel a part of the neighborhood where you live? 14.How does this patient describe their various roles in life? 15.Does this patient have positive role models for these roles? 16.Which relationships are most important to this patient at present? 17.Is this patient currently going through any big changes in role or relationship? If so, what are they?

Functional Health Pattern Nutritional-Metabolic 1.Does the client seem well nourished and developed in general? What does the skin and hair look like? 2.Is the client overweight or underweight for their age and height? 3.What is your daily dietary pattern? Describe your daily food and fluid intake. What are your food preferences and food dislikes? 4.Compare the patients food choices with the recommended daily allowances. 5.Do you eat three meals a day? (if more or less, describe.) 6.Do you take any vitamins or food supplements? 7.What type of snacks do you eat? 8.Do you understand the food pyramid? 9.Have you had any recent weight loss or weight gain? 10.What is your current weight? What is your desired weight? 11.Please describe how your wounds heal? 12.Do you have any food allergies or eating discomforts? 13.Do you have any diseases that affect your nutritional metabolic function? 14.Do you have difficulty swallowing? 15.How would you describe your energy level? 16.Do you have high cholesterol or blood pressure? Do you feel it is related to your diet? 17.When you are anxious do you have changes in your appetite? 18 How would you describe the reason you eat: necessity, pleasure, social event, religious symbol, cultural reasons, medical treatment, or a political statement.

Functional Health Pattern Activity-Exercise 1.What are your usual daily activities? 2.How do you describe your weekly pattern of activity and leisure? 3.Do you have sufficient energy for desired or required activities? 4.How would you describe your ease of movement? 5.How would you describe your general level of physical fitness? 6.What is your usual level of exercise per day or week? Type and regularity? 7.Do you have any diseases that affect your cardiac or respiratory or musculoskeletal system, which may have an effect on your activity-exercise? 8 Do you have dyspnea, chest pain, palpitations, stiffness, aching or weakness with activity? 9.What recreations or activities give you the most pleasure? 10.Do you need help with home maintenance? 11.Are you satisfied with your level of activity? 12.Do you smoke? If yes, how much per day? How may years? 13.Are you able to care for yourself? (bathe, groom, feed, dress, toilet, cook, etc.) 14.Do you feel that your body maintains proper alignment? 15.Do you experience problems of immobility such as appetite reduction, constipation, swollen ankles, urinary retention, urinary incontinence. 16.Do you sweat during exercise? Do you replace the fluids by drinking water? 17.Do you have dizziness with positional changes? 18.Arc there friends or family that play a role in your activity and exercise? Functional Health Pattern Elimination 1.What is your usual pattern of elimination? How frequently do your bowels move and how often do you void? What is the color & consistency of stools? 2.Have you recently experienced any changes or difficulties with your elimination? if yes, do you know what is the cause? 3.Do you use enemas, laxatives, or straight caths to promote elimination? 4.Do you experience constipation, fecal impaction, diarrhea, bowel incontinence, or excessive flatulence (gas)? 5.What are your personal daily habits, (nutrition, fluid intake, exercise)? 6.Do you feel that you take medications that may affect your elimination? 7.Does your elimination pattern interfere with your activities? 8.Do you ignore the urge to evacuate urine or stool? 9.Do you drink alcohol? 10.Have there been any recent dietary changes? 11.Do you ever have small amounts of liquid stool? 12.Does your elimination ever affect your skin integrity? 13.Do you get up at night to void? If so, how many times? 14.Do you have pain or difficulty with evacuation of your urine or stool? 15.Do you have urinary incontinence with coughing or sneezing? 16.Do you incorporate pelvic muscle (Kegal) exercises or use bowel and bladder training? 17.Do you have urinary incontinence, hesitancy, poor stream, blood in urine, urgency, frequency, or bladder dissention? 18.Do you have excess perspiration, odor problems, or itching of the perineum?

Functional Health Pattern Health Perception-Health Management 1.How would you describe your current health? 2.What practices do you do to improve or maintain your health? 3.What do you know about life style choices and health? 4.What is the reason for your visit to this facility? 5.Have you had any colds, flu, or illnesses in the past year? 6.What maintenance checks do you do to maintain your health? (Mammograms, testicular checks, breast self-exam, other, etc.) 7.What is your family health history? 8.Do you have any health risk factors as cigarette smoking, drug use, alcohol consumption, poor dietary maintenance? 9.What are you allergic to? Do you do anything to avoid problems? 10.Are your immunizations up to date? 11.Have there been any important illnesses or injuries in your life? 12.What current medications are you taking and what is their purpose? 13.Is the financial burden of health care a problem for you? 14.Are you exposed to home, school, or occupational safety hazards? 15.Describe your cause of illness and what actions are being taken to manage it?

LO, TC 2009