Health And Lifestyle Assessment - InnerWisdom


HealthandLifestyleAssessmentJoAnne Mandel, CNS, RN, LMSWInnerWisdom, Inc.2012

InnerWisdom, Inc.ASSESSMENT AND QUESTIONNAIREDIRECTIONSThis Assessment Questionnaire is meant to help you review nearly every aspect of your life. It wascompiled in accordance with the holistic methodology that allows each individual to take stock oftheir life from many perspectives. Please complete the following questionnaire by answering ALLquestions to the best of your ability. It is important to be as honest as possible when answering eachquestion. Be sure to give a brief explanation to specific questions, when applicable. Not all of thequestions in this assessment will pertain to you. If they do not, identify those questions byanswering Not Applicable (N/A).It is important that this questionnaire be completed as fully as possible before you begin theworkbook chapters. If you are working with a therapist, counseling pastor, or other healthcareprofessional, they can review the Assessment with you. However, if it is too difficult, it is notnecessary to share the information with others immediately. You may choose to wait for a time thatbetter suits you.SOCIAL HISTORYPlace of Birth:Date of Birth:Age:Race/ethnicity - check one:CaucasianAfrican AmericanNative AmericanHispanic/Mexican DescentAsianOtherReason for seeking life changes:Length of time you have experience problems?Date(s) of hospitalization for this condition (if any)?Define and discuss problems of social development; adjustment to life situations [, peer groups, community, family relationships, response to authority figures, use ofleisure time]:Cultural influences; ethnic factors which may be significant:

EDUCATION:Please circle the last year of school that you completed:1 2 3 4 5 6 7 8Grade School9 10 11 12High School13 14 15 16CollegeHigh School attended:College attended:College attended:17 18 19 20 21Master's DoctorateMajor:Major:My grades were/are:Approximate Grade Point Average:High SchoolCollegeExcellentAbove averageAbout averageBelow AverageAttitude towards school and teachers?Extra Curricular Activities:Did you leave home to attend college?Band/ChoirTheater ArtsCreative ArtsClass OfficerSportsOtherNoYesIf yes, at what age?FAMILY OF ORIGIN:Is your father living?NoYesIf no, year of death:If no, cause of death:If no, your age at the time of his death:If yes, how old is he now?His age at time of death:Describe your father's occupation when you were growing up:Circle the last year of school that your father completed:1 2 3 4 5 6 7 8Grade School9 10 11 12High School13 14 15 16College17 18 19 20 21Master's DoctorateWhen you were growing up was your father a/an:Alcohol or drug addict/abuserPhysical/sex/other abuserFood addict/abuserPrescription drug addict/abuser

Describe your father's personality and his attitude towards you as you were growing up.How would you describe your relationship with your father now? Skip if deceased.ExcellentGoodAverageBelow averagePoorIs your mother living?NoYesIf no, year of death:If no, cause of death:If no, your age at the time of her death:If yes, how old is she now?Age:Describe your mother's occupation when you were growing up:Circle the last year of school that your mother completed:1 2 3 4 5 6 7 8Grade School9 10 11 12High School13 14 15 16College17 18 19 20 21Master's DoctorateWhen you were growing up was your mother a/an:Alcohol or drug addict/abuserPhysical/sexual/other /abuserFood addict/abuserPrescription drug addict/abuserGive a description of your mother's personality and her attitude toward you as you were growing up.How would you describe your relationship with your mother now? Skip if deceased.ExcellentGoodAverageBelow averagePoor

How would you describe your family's attitude toward you when you were growing up? Pleaseexplain.Were your parents ever separated or divorced?NoYesIf yes, how old were you at the time?Please describe your home atmosphere as you were growing up. Mention state of compatibilitybetween parents and between parents and children.Who raised you as a child?How many brothers and sisters do you have?Brothersliving Cause of deathdeceasedSistersliving Cause of deathdeceasedcause of deathcause of deathIn the space below, please provide the information requested on each of your brothers andsisters.1 Severe problems; 2 Many problems; 3 About average; 4 Some problems; 5 Well adjustedSibling #First NameAgeSexWeightHeightDescription - Circle ONESibling 112345Sibling 212345Sibling 312345Sibling 412345Sibling 512345Sibling 612345Sibling 712345Sibling 812345PRESENT RELATIONSHIPS:What is your usual living arrangement?What is your present marital status?

Living aloneLiving with partnerSeparatedLiving with a spouseLiving with family; specify;Never marriedLiving with others; specify:Living in a communal society; specify:MarriedLiving with a roommate/partnerSeparatedDivorcedWidowedPlease provide the following information for each marriage:StartDateEndDateName ofSpouseReason for Termination[Death, Divorce, etc.]Number of Childrenfrom this MarriageNames ofChildrentototoPlease answer the following questions about your spouse/partner. If not currently married, butpreviously married, answer the following questions about your former spouse/partnerIs/was your spouse employed?NoYesWhen employed, what kind of work did your spouse do?Please circle the last year of school that your spouse completed:1 2 3 4 5 6 7 8Grade School9 10 11 12High School13 14 15 16College17 18 19 20 21Master's DoctorateSEXUALITY:What was your parents' attitude about sex?When and how did you derive your first knowledge of sex?When did you first become aware of your sexual impulses?Have you ever thought you needed help for your sexual thoughts or behaviors?YesNoIf yes, please explain:

Do you ever resort to sex to escape, relieve anxiety, or cope with stressful situations?YesNo If yes, please explain:Have you ever been arrested for a sex related offense?YesNo If yes, please explain:Have you noticed physical symptoms such as nausea, knot in your stomach, or hot flashes whenapproached sexually?YesNo If yes, please explain:How old were you when you masturbated for the first time?How old were you when you had an orgasm for the first time?How old were you when you had sexual intercourse for the firsttime?years old.years old.years old.Did you ever have any anxiety or guilt feelings about masturbation or having sexual intercourse?If yes, please explain.Have you been sexually abused or raped? If yes, please explain. By whom?Have you been in recovery for sexual abuse?How long?Is your present sex life satisfactory? If not, please explain.Have you ever had an abortion?YesNo What age?Please explain.How many children do you have (including children from previous marriages whether they areliving with you or not)?sonslivingdeceaseddaughterslivingdeceased

Please provide the information requested for your children.1 Severe problems; 2 Many problems; 3 Average; 4 Some problems; 5 Well adjustedChild #First Name Age Sex Weight HeightDescription - Circle ONEChild 112345Child 212345Child 312345Child 412345Child 512345Child 612345Child 712345Child 812345VOCATION/EMPLOYMENT:Are you employed?YesNoName of employer?Briefly describe the kind of work you do.How long have you done this kind of work?Does your present work satisfy you?yearsYesIf not, in what ways are you dissatisfied?What would you like to do?What jobs have you held in the past?What were your vocational ambitions in the past?What are your vocational ambitions now?No

What is the total annual income of your family? Check ONEUnder 12,000Between 12,000 and 20,000Between 20,000 and 35,000Between 35,000 and 60,000Over 60,000MILITARY HISTORYBranch of Service?Rank?Type of Duty?Length of Service?Type of Discharge?Adjustment to Military Life?LEGAL DIFFICULTIES:DUI?YesNoIf Yes, please explain and give dates.Other difficulties including lawsuits, legal guardianship, custody of minor child(ren).Additional legal difficulties:RELIGION/SPIRITUALITY:Do you believe in God?YesNoIn what religion were you raised?CatholicJewishProtestant specify:Fundamental Protestant specify:BuddhistMuslimHinduAgnosticNo ReligionOther specify:Which describes best how your family that you grew up in practiced religion?Actively participated [went to church several times a week]Moderately participated [went to church once a week]Occasionally participated [went to church every once in a while]Rarely participated [only went on holy days such as Easter]Never participated [stated they believed in God but never went to church]My family of origin had no religion in which to participate

Which describes best how you feel about your religious upbringing?Religion was beaten into meReligion was a good experienceI am angry about being forced to go to churchI am grateful for my religious upbringingMy religious upbringing is irrelevant to my lifeI have no particularly strong feelings about my religious upbringingAs a child, I understood God as being:Loving and generousWrathful and angryEverywhere as in nature but powerless to help meRemoved from my daily lifeCould not imagine GodWanted to believe in God but had difficultyGod? Who cares?As a child, my greatest religious concern was:Heaven and hellGuilt and punishmentLove and graceSatan/the devil and evilBeing good or being badFearful of God's punishmentDeathI had no religious concernsHow did your parents respond to your grief?They ignored itThey helped me through it and comforted meThey told me to stuff my feelingsThey got angry at my feelingsThey showed disgust at my feelingsThey did not see me or my feelings [I felt invisible]Do you feel your faith or religion has been:A vital part of your lifeImportant, but not vitalSomething you can take or leaveThe source of all your problemsHave had no faith or religion as an adultPlease explain:Now I understand God as beingLoving and generousWrathful and angryEverywhere as in nature but powerless to help meRemoved from my daily lifeCan not imagine GodWant to believe in God but have difficultyGod? Who cares?This isSimilar toDifferent from my childhood belief.Which of the following contributes to your inability to find peace of mind?HopelessnessDespair

DepressionSelf-hateLack of disciplineImpatienceResentmentConstant lyingSex issuesOther specify:Do you feel you have done something that is so bad you cannot be forgiven?YesNoPlease explain.HOBBIES/INTERESTS:What are your present interests, hobbies and activities?How much time do you spend in leisure activities?Do you prefer spending leisure time alone or with others? Why?How is most of your leisure time occupied?What would you like to change about your leisure time and the way it is spent? Please explain.PSYCHIATRIC HISTORY:Does anyone in your family have a psychiatric illness, such as depression, alcoholism, drugdependence or an eating disorder? Please give details.Are there any other members of the family about whom information regarding illness, etc., isrelevant?

List any situations that make you feel stressed.List any situations, which make you feel calm or relaxed.How were you referred to a treatment or self-help Program?Family member [relationship]:Physician [name]:Therapist [name]:FriendClergyInternetOther specify:Below, briefly state your expectations concerning a treatment or self-help Program.benefits do you want to derive?WhatMEDICAL HISTORY:What are your present medical problems?What are your past medical problems?What medication or drugs are you taking? Please list names and amounts, including any for weightcontrol and including birth control pills.NAME OF MEDICATION OR DRUGAMOUNTAre you allergic to any medication, drugs or foods?NoHOW OFTENREASON

YesIf yes, please list which and what reaction you have; e.g. "rash".When did you last have a complete physical exam?Date [Month, Day, Year]://Who is your current medical doctor?ADDICTIONS HISTORY:How much alcohol do you currently drink?In the past?One or more drinks dailyTwo or more drinks a weekOne drink a weekOne drink a monthLess than one drink a monthOne or more drinks dailyTwo or more drinks a weekOne drink a weekOne drink a monthLess than one drink a monthSpecify type(s) of alcohol:Are you currently anAlcoholicDrug addictPrescription drug addictFood addictRecovering alcoholicRecovering drug addictRecovering prescription drug addictRecovering food addictPlease indicate your current use of nsMarijuanaTranquilizersOtherPlease indicate your past use of oin- 13 -

HallucinogensMarijuanaTranquilizersOtherHow many cigarettes do you currently smoke daily?In the past?Three packs or moreBetween one and three packsOne to three packsLess than one packThree packs or moreHow long have you smoked?How many cups of coffee do you drink daily?Six cups or moreThree to five cupsOne or two cupsNoneHow many cups of soda do you drink daily?Six cans or moreThree to five cansOne or two cansNoneAre they "diet" sodas?Are they caffeine free?YesYesNoNoHow many hours of sleep do you need to feel your best?Ten hours or moreEight to ten hoursSix to eight hoursLess than six hoursCheck one:I get enough sleep.I do not get enough sleep.I sleep too muchHow would you describe your overall physical health? Check oneExcellentBetter than averageAverageWorse than averagePoorList health problems or symptoms:MENSTRUAL HISTORY: [MALES SKIP]- 14 -

How old were you when your first menstrual period began?years oldNot Applicable [for females who have never menstruated]Are you on birth control?YesNoHow many times have you missed your period for 2 consecutive months or more (excludingpregnancy)?TimesNeverPlease complete the following for each time your menstrual period stopped:Most Recently Previous Time Previous TimePrevious TimeDateWeightDate resumedWeight resumedEXCEPT for any times when your periods may have stopped because of a major weight loss orgain, what is the approximate regularity of your periods?Fairly regular [same number of days, not more than 3 days early, late]Somewhat irregular [within 4 to 10 days early or late]Very irregular [more than 10 days early or late]PRIOR HEALTH HISTORY:NOT COUNTING HOSPITALIZATION FOR CHILDBIRTH, please list all hospitalizations,indicating your age and the reason for each admission:AGEREASON FOR HOSPITALIZATIONPlease list any serious illnesses you have had which DID NOT REQUIRE HOSPITALIZATION:AGEILLNESSHave you ever received psychiatric therapy or are you now receiving psychiatric therapy?- 15 -

No, neverYes, in the past.Yes, at present.Why?Why?Please complete the section below regarding your psychiatric therapy.AgeReason for ContactType of Therapy Received Length of TreatmentATTITUDE TOWARD PRESENT LIFE SITUATION:Please check the following responses that apply to you:take sedativesfeel panickysuicidal ideassexual problemsinferiority feelingsover-ambitiousshy with peopleunable to have a good timecan't make decisionshome conditions badconcentration difficultiesdon't like weekends & vacationsheadachespalpitationsbowel disturbancesnightmaresfeeling tensedepressedeat too muchdizzinessstomach troublefatigueOthers:Check the following words, which apply to you:- 16 -can't make friendscan't keep a jobfinancial problemsunable to relaxfainting spellsno appetiteinsomniaalcoholismtremorstake drugsmemory problems

worthlessinadequatecan't do anything righthorrible idfull of regretshostilecowardlyuglylonelyattractivea "nobody"incompetentevilfull of hateunassertivedeformedunlovedworthwhilelife is emptynaivemorally wrongconsiderateboredin Others:DO YOU HAVE A HISTORY OF:Yes NoHeart DisordersAsthma/EmphysemaOther Lung DisordersHigh Blood PressureRheumatoid ArthritisStress Related TensionCirculatory DisordersMigraine HeadachesTension HeadachesRecent InfectionsPsychological DisorderKidney DisordersNervous DisordersSinus ProblemsSkin AllergiesGastrointestinal DisturbancesFluid RetentionHay feverTightness of throatThyroid troubleTwitching of faceFatigueHead feels heavyLoss of balanceLight bother eyesTightness of shoulder musclesPins & needles in arms & handsChest painsShortness of breathHeart palpitationHigh blood pressureAnemiaNervous stomachUlcersCold sweatsGall bladder troubleConstipationSleeping problemsPins & needles in legsPains in legs & feetYes NoDiabetesCancerAids/HIVAny ImplantsBroken BonesBack ProblemsNeck ProblemsRecent FeverRecent PainChronic PainBlood ClotsTMJ ProblemsNumbnessDizzinessEdemaRespiratory AllergiesLoss of smellLoss of tasteInflammation/throatFace FlushedLoss of memoryDepressionFaintingRinging in earsGrating in neckNeuritis in shoulder & armsCold handsSeizuresT.BHeart attacksLow blood pressureRheumatic feverStomach troubleIrritabilityLiver troubleIndigestionBladder troubleSwollen jointsCold feetPhlebitis- 17 -

Varicose veinsKnee painStressHormone balanceStimulation of hair growthHepatitisUrinary problemsVenereal diseaseSensitive to touch/in any areaShoulder painWeight controlPost stroke symptomsEnergy build-upInsomniaG.I. ProblemsMuscular/SkeletalEpilepticWear contact lensesMALES ONLY:FEMALES ONLY:Prostate troubleUrination difficultyFrequent night urinationBurning upon urinationPersistent abdominal painPain on inside of legs or heelsPain in groin areaLow back painTire too easilyLack of energyExcessive perspirationDiminished sex driveBurning or pain during orgasmEasily fatiguedPre-menstrual stressTensionDepressionPainful menstruation crampsMenstruation excessive & prolongedMenstruation scanty or missingVaginal DischargePainful breastsMenopausal hot flashes, etc.Melancholia of long standingI.U.D. diaphragmBirth control pillsAre you pregnant?Last menstrual periodHow many pregnancies?Last pap SmearAre you taking any of the following? Check those that applyLaxativesAspirinSleeping essantAntihypertensiveMedical Prescriptions (list all)- 18 -

Lifestyle Assessment JoAnne Mandel, CNS, RN, LMSW InnerWisdom, Inc. 2012 . InnerWisdom, Inc. ASSESSMENT AND QUESTIONNAIRE DIRECTIONS This Assessment Questionnaire is meant to