Spirituality
• Do you have a formal religion or believe in a power higher than yourself?
• If you have these beliefs, what do you believe about them? Is this power to be feared or is it good?
• Do you believe that all life has meaning?
• Is there an underlying order in the universe, or do events occur randomly and without purpose?
• What do you value in life?
• What do you need to bring about your best self and the traits you most admire?
• Are you most motivated by faith, love, or fear?
• Is hope important in your life? If so, in what way?
• Do you perform any practices or rituals to help you connect with your spirituality?
• Do you believe your actions are congruent with your values and beliefs?
• Describe how your values/beliefs affect your health/health care.
• Are you involved in activities that you feel contribute to the betterment of humanity?
Nutrition
• Are you currently at your ideal weight?
• How do you perceive your current dietary habits?
• In what areas would you like to improve your nutrition?
• How many glasses of water do you drink daily?
• How may servings of fruits and vegetables do you eat daily?
• How many alcoholic beverages do you drink?
• What is your source of protein and how many servings do you eat daily?
• How many servings of dairy products/day?
• How many servings of grains/day?
• How many sweet/sugar containing foods and beverages do you consume daily?
• How many caffeinated beverages do you consume daily?
• How many servings of fried food do you consume?
• Do you routinely salt your food?
• Do you buy organic foods?
Exercise
• Do you currently exercise?
• Rate your perception of your flexibility and strength.
• How much endurance do you have during activities?
• Are you able to complete your activities of daily living?
• How much energy do you have? Is it enough to meet the requirements of your daily life activities?
• Rate your perception of your current exercise habits?
• How much exercise and what type do you get per week?
• Are you ever short of breath during exercise or routine activities?
Culture
• Do you speak/read any other language besides English?
• What are your family’s health beliefs?
• Who makes major health decisions in the family?
• Do you have any cultural dietary practices?
• Do you seek the care of a physician as a first response or a last resort when you are ill?
• What type of food do you prefer/dislike?
• What do you believe promotes health?
• What are your health/illness beliefs and practices?
• What diseases/disorders are prevalent in your family?
Alternative medicines and practices:
• Do you take any dietary supplements such as vitamins or minerals?
• Do you take any herbal medications?
• Do you practice any alternative medicine for stress reduction or health promotion such as acupressure, acupuncture, massage therapy, guided imagery, reiki, meditation, etc
• If you do not currently pursue alternative medicine practices, are you open to pursuing such practices?
Stress reduction and psychosocial health
• How many hours do you sleep at night on average?
• Do you have difficulty falling asleep or remaining asleep?
• Do you use sleep aids?
• Do you wake up refreshed or tired?
• Do you routinely incorporate relaxation into your day? How often and what type?
• What do you do for fun and pleasure?
• How would you describe your emotional response to stress?
• Are you aware of your feelings when involved in a difficult situation?
• Rate your ability to express your feelings, 10 being most able.
• Are you able to share your feelings without seeking the approval of others or fearing the outcomes?
• Are you satisfied with how you handle your feelings?
• Do you tend to avoid difficult conversations or situations?
Support systems
• Describe your social contacts such as friends, coworkers, other activities.
• Describe your closest relationships?
• Do you have a life partner?
• Are you satisfied with your relationships?
• Are you satisfied with your level of social interaction?
• To whom do you turn for support?
Risk factors (client’s perception of own risk factors and current health concerns due to genetics, family health history, environment, current health practices, etc):
• Obtain information from a family medical health genogram to identify familial health risks
• Do you smoke?
• Do you use drugs not prescribed by your doctor?
• How much sun exposure do you get daily?
• Do you wear a seat belt when driving?
• Do you text and drive?
• Are you regularly around hazardous equipment?
• Are you around any pollutants, allergens, chemicals, or other irritants on a regular basis?
• Are there any health concerns in your family history?
• Recent hospitalizations or need for primary care provider visit?
• Medications used to treat primary health concerns?
• What are your most important goals as a result of this assessment?
