V. Functional Assessment (15 marks): |
Self-Esteem, Self-Concept: |
Education level: (last year of schooling/ last grade completed) & Other significant training) |
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Financial status: (Monthly income, income adequate for lifestyle and/or health concerns) |
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Value-belief system: (religious practices and perception of personal strengths) |
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Activity/Exercise: A daily profile reflecting usual daily activities. “Tell me how you spend a typical day.” |
Ability to perform ADLs: (independent or needs assistance with feeding, bathing, hygiene, dressing, toileting, bed-to-chair transfer, walking, standing, or climbing stairs) |
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Is there any use of wheelchair, prostheses, or mobility aids? |
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Leisure activities enjoyed and the exercise pattern: (type, frequency and duration per day or week, method of warm-up session, method of monitoring the response of the body to exercise). |
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Sleep/Rest: (Sleep patterns (hours of sleep and arising), daytime naps, any sleep aids used) |
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Nutrition/Elimination. Recall of all food and beverages taken over the past 24 hours. Ask, “Is that menu typical of most days?” |
Dietary Consideration (Food preferred/like to eat): |
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Dietary Restrictions (Food dislike or not allowed to eat): |
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Any food allergy or intolerance: |
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Daily intake of caffeine (coffee, tea, cola drinks): |
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Regularity of stools and urination/ how many times a day: |
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Problems with mobility or transfer in toileting, continence, use of laxatives: |
Interpersonal Relationships/Resources: |
Primary Care Provider: |
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Current house-hold: |
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Social roles: “How would you describe your role in the family? How would you say you get along with family, friends, and co-workers?” |
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Support systems: “To whom could you go for support with a problem at work, your health, or a personal problem?” |
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Contact with others: “Is time spent alone pleasurable and relaxing, or is it isolating?” |
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Spiritual Resources: Use the Faith, Influence, Community, and Address (FICA) questions |
Faith: “Does religious faith or spirituality play an important part in your life? Do you consider yourself to be a religious or spiritual person?” |
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Influence: “How does your religious faith or spirituality influence the way you think about your health or care for yourself?” |
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Community: “Are you a part of any religious or spiritual community or congregation?” |
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Address: “Would you like me to address any religious or spiritual issues or concerns with you?” |
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Coping and Stress Management: |
Is there any change in lifestyle or any current stress? |
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What methods you have tried to relieve stress and whether these have been helpful? |
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Personal Habits: |
Tobacco: “Do you smoke cigarettes (pipe, use chewing tobacco)? At what age did you start? How many packs do you smoke per day? How many years have you smoked?” “Have you ever tried to quit?” and “How did it go?” |
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Alcohol: Cut down, Annoyed, Guilty, and Eye-opener (CAGE) test |
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Illicit or Street Drugs: prescription painkillers, frequency of use and how use has affected work or family. |
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Environment/Hazards: |
Housing and neighborhood (living alone, knowledge of neighbors): |
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Any hazards in workplace and at home |
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Use of seatbelts: |
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Travel or residence in other countries, including time spent abroad: |
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Occupational Health: |
Occupation: What is your job? |
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Exposure History: Ever worked with any health hazard such as asbestos, inhalants, chemicals, repetitive motion? |
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Wear any protective equipment? Any work programs in place that monitor exposure? Aware of any health problems now that may be related to work exposure? |
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What do you like or dislike about the job? |
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