Patient Assessment

Patient Assessment EN

THIS IS A CONFIDENTIAL QUESTIONNAIRE TO HELP US DETERMINE THE BEST TREATMENT PLAN FOR YOU. PLEASE FILL IT OUT AS COMPLETELY AS POSSIBLE. THANK YOU.

50
Gender
Current address & living country
Current address & living country
City
State/Province
Zip/Postal
Country

Past health history:

Tobacco/ alcohol USE:

Live with a smoker?

PRESENT HEALTH

Perception and Health Management Pattern

Medical report (Attached)

Maximum file size: 5MB

Maximum file size: 5MB

Maximum file size: 5MB

Maximum file size: 5MB

Maximum file size: 5MB

Maximum file size: 5MB

Current Medicine and supplement

Name/Description, Dosage/Quantity, Frequency, REASON

Maximum file size: 5MB

Nutritional Assessment

(e.g., food preferences or restrictions, special diet, appetite); actual weight; weight loss or gain
75
150
Appetite
Do you find yourself eating processed foods often? (This includes red and packaged meats, frozen meals, and white bread but excludes homogenized milk and frozen veggies)
Do you have any physical conditions that restrict food intake, such as mouth ulcers, difficulty swallowing?

ELIMINATION PATTERN

SLEEP-REST PATTERN

Describes patterns of sleep, rest, and relaxation
Are you using any medication for sleeping?

ACTIVITY-EXERCISE PATTERN

Describes patterns of exercise, activity, leisure, and recreation; ability to perform activities of daily living

Respiratory

Need oxygen support

PAIN

Value-Belief Pattern

Please circle the number (0-10) that describes the best of your distress level over the weeks.
How often is stress a problem for you in handling? such things as: your health, your finances, your family or social relationships or your work
How often do you get the social and emotional support you need?

FOR WOMEN

Tell me about your menstrual history (onset, length, amount of flow, cramps, bloating, PMS, age of first period, age of menopause).
Menopause at age
If yes, were your ovaries removed?
History of abnormal pap smear?