1. History
a. How has general health been?
b. Any colds in past year? When appropriate: absences from work?
c. Most important things you do to keep healthy? Think these things make a difference to health? (Include family folk remedies when  ppropriate.) Use of cigarettes, alcohol, drugs? Breast self-examination?
d. Accidents (home, work, driving)? e. In past, been easy to find ways to follow suggestions
from physicians or nurses?
f. When appropriate: what do you think caused this illness?
Actions taken when symptoms perceived? Results
of action?
g. When appropriate: things important to you in your
health care? How can we be most helpful?
2. Examination—general health appearance
1. History
a. Typical daily food intake? (Describe.) Supplements (vitamins,
type of snacks)?
b. Typical daily fluid intake? (Describe.)
c. Weight loss or gain? (Amount.) Height loss or gain?
d. Appetite?
e. Food or eating: Discomfort? Swallowing? Diet
f. Heal well or poorly?
g. Skin problems: Lesions? Dryness?
h. Dental problems?
2. Examination
a. Skin: Bony prominences? Lesions? Color changes?
b. Oral mucous membranes: Color? Moistness? Lesions?
c. Teeth: General appearance and alignment? Dentures?
Cavities? Missing teeth?
d. Actual weight, height.
e. Temperature.
f. Intravenous feeding–parenteral feeding (specify)?
1. History
a. Bowel elimination pattern? (Describe.) Frequency?
Character? Discomfort? Problem in control?
b. Urinary elimination pattern? (Describe.) Frequency?
Problem in control?
c. Excessive perspiration? Odor problems?
d. Body cavity drainage, suction, and so on? (Specify.)
2. Examination—when indicated: examine excreta or drainage
color and consistency.
1. History
a. Sufficient energy for desired or required activities?
b. Exercise pattern? Type? Regularity?
c. Spare-time (leisure) activities? Child: play activities?
d. Perceived ability (code for level) for:
Feeding Dressing Cooking
Bathing Grooming Shopping
Toileting General mobility
Bed mobility Home maintenance
Functional Level Codes:
Level 0: full self-care
Level I: requires use of equipment or device
Level II: requires assistance or supervision from
another person
Level III: requires assistance or supervision from
another person and equipment or device
Level IV: is dependent and does not participate
2. Examination
a. Demonstrated ability (code listed above) for:
Feeding Dressing Cooking
Bathing Grooming Shopping
Toileting General mobility
b. Gait ________ Posture Absent body part?
c. Range of motion (joints) Muscle
d. Hand grip Can pick up a pencil?
e. Pulse (rate) (rhythm) Breath
f. Respirations (rate) (rhythm) Breath
g. Blood pressure
h. General appearance (grooming, hygiene, and energy
1. History
a. Generally rested and ready for daily activities after
b. Sleep onset problems? Aids? Dreams (nightmares)?
Early awakening?
c. Rest-relaxation periods?
2. Examination
a. When appropriate: Observe sleep

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