Gordon’s Health Patterns Wellness Assessment Questionnaire

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Gordon’s Health Patterns Wellness assessment questionnaire 1. Health Perception-Health Management Pattern a. How is your family’s general health? What does your family do to stay healthy? b. Do you have regular health checkups? c. Does anyone in your family drink alcohol or smoke? 2. Nutritional-Metabolic Pattern a. Does your family eat healthy? What kind of food do you generally eat? b. How much fluid does your family generally consume? c. Is anyone in your family over or under weight? 3. Elimination Pattern a. What is your family’s regular bowel elimination pattern? b. What is your family’s regular urinary elimination pattern? c. Has anyone in your family experienced any discomfort or noticed anything unusual related to their bowel or urinary elimination? 4. Activity-Exercise Pattern a. How often does your family exercise? b. Does your family participate in sports? c. What do you like to do in your spare time? 5. Sleep-Rest Pattern a. Do you generally get enough rest to perform your daily activities without issues? b. Do you have trouble sleeping? Do you use any medication or other products to help you sleep? c. Do you feel fresh when you wake up? 6. Cognitive-Perceptual Pattern a. Does anyone in your family have trouble hearing or seeing? b. Does your family have routine eye exams? c. What’s the best way for you to learn and do you ever have trouble learning new things? 7. Self-Perception – Self-Concept Pattern a. Do you generally feel good about yourself? b. Do you ever feel that you have lost hope? c. How do you feel when you look in the mirror? 8. Roles-Relationships Pattern a. Do you currently live alone, with family, or with others? b. Did you grow up in a big or small family? c. Do you belong to any

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