HEALTH HISTORY
Health Perception–Health Management
• How is your energy level compared with 1 yr ago?
• Do you notice any visual changes?*
• Have you ever smoked? If yes, how many packs per day?
Nutritional-Metabolic
• How is your appetite?
• Has your weight changed over the past yr?*
• Do you take vitamins, herbs, or any other supplements?*
• How much and what kinds of fluids do you drink daily?
• How many dairy products and how much meat do you eat?
• Do you drink coffee? Colas? Tea?
• Do you eat chocolate?
• Do you spice your food heavily?*
Elimination
• Are you able to sit through a 2-hr meeting or ride in a car for 2 hr without urinating?
• Do you awaken at night with the desire to urinate? If so, how many times does this occur during an average night?
• Do you ever notice blood in your urine?* If so, at what point in the urination does it occur?
• Do you ever pass urine when you do not intend to? When?
• Do you use special devices or supplies for urine elimination or control?*
• How often do you move your bowels?
• Do you ever experience constipation?
• Do you frequently experience diarrhea? Do you ever have problems controlling your bowels? If so, do you have problems controlling the passage of gas? Watery or liquid stool? Solid stool?
Activity-Exercise
• Have you noticed any changes in your ability to do your usual daily activities?*
• Do certain activities aggravate your urinary problem?*
• Has your urinary problem caused you to alter or stop any activity or exercise?*
• Do you require assistance in moving or getting to the bathroom?*
Sleep-Rest
• Do you awaken at night from an urge to urinate?*
• Do you awaken at night from pain or other problems and urinate as a matter of routine before returning to sleep?*
• Do you experience daytime sleepiness and fatigue as a result of nighttime urination?*
Cognitive-Perceptual
• Do you ever have pain when you urinate?* If so, where is the pain?
Self-Perception–Self-Concept
• How does your urinary problem make you feel about yourself?
• Do you perceive your body differently since you have developed a urinary problem?
Role-Relationship
• Does your urinary problem interfere with your relationships with family or friends?*
• Has your urinary problem caused a change in your job status or
affected your ability to carry out job-related responsibilities?*
Sexuality-Reproductive
• Has your urinary problem caused any change in your sexual pleasure or performance?*
• Do you have hygiene problems related to sexual activities that cause you concern?*
Coping–Stress Tolerance
• Do you feel able to manage the problems associated with your urinary problem? If not, explain.
• What strategies are you using to cope with your urinary problem?
Values-Beliefs
• Has your present illness affected your belief system?*
• Are your treatment decisions related to your urinary problem in conflict with your value system?*