Health Perception- Health Management Pattern
Left Nostril: Normal ___ Abnormal ___
Objective
1. Mental Status
a. Oriented ___ Disoriented ___
Time: Yes ___ No ___
Place: Yes ___ No ___
Person: Yes ___ No ___
b. Sensorium
Alert ___ Drowsy ___ Stuporous ___Comatose ___
Cooperative ___ Combative ___ Delusional ___
c. Memory
Recent: Yes ___ No ___
Remote: Yes ___ No ___
2. Vision
a. Visual activity: Both eyes 20/___; Right 20/___;
Left 20/___; Not assessed ___
b. Pupil size
Right: Normal ___ Abnormal ___
Left: Normal ___ Abnormal ___
c. Pupil reaction
Right: Normal ___ Abnormal ___
Left: Normal ___ Abnormal ___
3. Hearing
a. Not assessed ___
b. Right ear: WNL ___ Impaired ___ Deaf ___
Left ear: WNL ___ Impaired ___ Deaf ___
c. Hearing aid: Yes ___ No ___
4. Taste
a. Sweet: Normal ___ Abnormal ___
Describe: ____________________________________
b. Sour: Normal ___ Abnormal ___
Describe: ____________________________________
c. Tongue movement: Normal ___ Abnormal ___
Describe: ____________________________________
d. Tongue appearance: Normal ___ Abnormal ___
Describe: ____________________________________
5. Touch
a. Blunt: Normal ___ Abnormal ___
Describe: ____________________________________
b. Sharp: Normal ___ Abnormal ___
Describe: ____________________________________
c. Light touch sensation: Normal ___ Abnormal ___
Describe: ____________________________________
d. Proprioception: Normal ___ Abnormal ___
Describe: ____________________________________
e. Heat: Normal ___ Abnormal ___
Describe: ____________________________________
f. Cold: Normal ___ Abnormal ___
Describe: ____________________________________
g. Any numbness: Normal ___ Abnormal ___
Describe: ____________________________________
h. Any tingling: Normal ___ Abnormal ___
Describe: ____________________________________
6. Smell
a. Right nostril: Normal ___ Abnormal ___
Describe: ____________________________________
b.
Describe: ________________________________
7. Cranial Nerves: Normal ___ Abnormal ___
Describe: ____________________________________
8. Cerebellar Exam (Romberg, balance, gait, coordination,
etc.) Normal ___ Abnormal ___
Describe: ____________________________________
9. Reflexes: Normal ___ Abnormal ___
Describe: ____________________________________
10. Any enlarged lymph nodes in the neck? No ___ Yes ___
Location and size: _____________________________
11. General appearance
a. Hair: ____________________________________
b. Skin: ____________________________________
c. Nails: ___________________________________
d. Body color: ______________________________
Subjective
1. How would you describe your usual health status?
Good ___ Fair ___ Poor ___
2. Are you satisfied with your usual health status?
No ___ Yes ___ Source of dissatisfaction
_____________________________________________
_____________________________________________
3. Tobacco
No ___ Yes ___ Number of packs per day
_______________________________________________
___________________________________________
4. Alcohol use
No ___ Yes ___ How much and what kind
_______________________________________________
_______________________________________________
5. Street drug use
No ___ Yes ___ What and how much
_______________________________________________
_______________________________________________
6. Any history of chronic disease
No ___ Yes ___ Describe
_______________________________________________
_______________________________________________
7. Immunization history: Tetanus ___ Pneumonia ___
Influenza ___ MMR ___ Polio ___ Hep B ___
8. Have you sought any health assistance in the past year?
No ___ Yes ___ If yes, why?
_______________________________________________
9. Are you currently working? No ___ Yes ___ Who would
you rate your working conditions (eg. Safety, noise, space,
heating, cooling, water, ventilation)?
Excellent ___ Good ___ Fair ___ Poor ___ Describe any
problem areas:
_______________________________________________
_______________________________________________
10. How would you rate living conditions at home?
Excellent ___ Good ___ Fair ___ Poor ___ Describe any 23. Do you do (breast or testicular) self-examination?
problem areas: No ___ Yes ___ How often?
_______________________________________________ _______________________________________________
_______________________________________________
11. Do you have any difficulty securing any of the following Nutrition-Metabolism Pattern
services? Objective
Grocery store: Yes ___ No ___ 1. Skin examination
Pharmacy: Yes ___ No ___ a. Warm ___ Cool ___ Moist ___ Dry
Health Care Facility: Yes ___ No ___ b. Lesions: No ___ Yes ___
Transportation: Yes ___ No ___ Describe: ____________________________________
Telephone (for police, fire, ambulance): Yes ___ No ___ c. Rash: No ___ Yes ___
If any difficulties, note referral here: Describe: ____________________________________
_______________________________________________ d. Turgor: Firm __ Supple __ Dehydrated __ Fragile __
_______________________________________________ e. Color: Pale ___ Pink ___ Dusky ___ Cyanotic ___
12. Medications (OTC and prescription) Jaundiced ___ Mottled ___
Name Dosage Times/ Reason Taken as Other: ______________________________________
day ordered 2. Mucous membranes
Yes No a. Mouth
i. Moist ___ Dry ___
ii. Lesions: No ___ Yes ___
Describe: _______________________________
iii. Color: Pale ___ Pink ___
iv. Teeth: Normal ___ Abnormal ___
13. Have you followed the routine prescribed for you? Describe: _______________________________
Yes ___ No ___ Why not? v. Dentures: No __ Yes __ ; Upper ___ Lower ___
_______________________________________________ Partial ___
14. Do you think this prescribed routine was best for you? vi. Gums: Normal ___Abnormal ___
Yes ___ No ___ What would be better? Describe: _______________________________
_______________________________________________ vii. Tongue: Normal ___ Abnormal ___
15. Have you had any accidents or injuries or falls in the past Describe: _______________________________
year? b. Eyes
No ___ Yes ___ i. Moist ___ Dry ___
Describe: _______________________________________ ii. Color of conjunctiva: Pale ___ Pink ___
16. Have you had any problems with cuts healing? Jaundiced ___
No ___ Yes ___ iii. Lesions: No ___ Yes ___
Describe: _______________________________________ Describe: _______________________________
17. Do you exercise on a regular basis? 3. Edema
No ___ Yes ___ Type and Frequency: a. General: No ___ Yes ___
_______________________________________________ Describe: ____________________________________
18. Have you experiences ringing in your ears: Abdominal girth: _____ inches
Right ear: Yes ___ No ___ b. Peiorbital: No ___ Yes ___
Left ear: Yes ___ No ___ Describe: ____________________________________
19. Have you experienced any vertigo? c. Dependent: No ___ Yes ___
Yes ___ No ___ How often and when? Describe: ____________________________________
_______________________________________________ Ankle girth: Right _____ inches; Left _____ inches
20. Do you regularly use seat belts? Yes ___ No ___ 4. Thyroid: Normal ___ Abnormal ___
21. For infants and children: Are care seats used regularly? Describe: _______________________________________
Yes ___ No ___ 5. Jugular vein distention: No ___ Yes ___
22. Do you have any suggestions or requests for improving 6. Gag reflex: Present: ___ Absent ___
your health? 7. Can patient move easily (turning, walking)? Yes __ No __
Yes ___ No ___ Describe: Describe limitations: ______________________________
_______________________________________________ 8. Upon admission was the patient dressed appropriately for
_______________________________________________ the weather? Yes ___ No ___
Describe: _______________________________________
 For breastfeeding mothers only:
9. Breast exam: Normal ___ Abnormal ___ Describe:
_______________________________________________
_______________________________________________
10. If mother is breastfeeding, have infant weighed. Is infant’s
weight within normal limits? Yes ___ No ___
Subjective
1. Any weight gain in the last 6 months? No ___ Yes ___
Amount: ________________________________________
2. Any weight loss in the last 6 months? No ___ Yes ___
Amount: ________________________________________
3. How would you describe your appetite?
Good ___ Fair ___ Poor ___
4. Do you have any food intolerance? No ___ Yes ___
Describe: _______________________________________
5. Do you have any dietary restrictions? (Check for those
that are a part of a prescribed regimen as well as those
that patient restricts voluntarily, for example to prevent
flatus) No ___ Yes ___
Describe: _______________________________________
6. Describe an average day’s food intake for you.
_______________________________________________
_______________________________________________
7. Describe an average day’s fluid intake for you.
_______________________________________________
_______________________________________________
8. Describe food:
Likes:
_______________________________________________
_______________________________________________
Dislikes:
_______________________________________________
_______________________________________________
9. Would you like to: Gain weight ___ Lose weight ___
Neither ___
10. Any problems with:
a. Nausea: No ___ Yes ___
Describe: ____________________________________
b. Vomiting: No ___ Yes ___
Describe: ____________________________________
c. Swallowing: No ___ Yes ___
Describe: ____________________________________
d. Chewing: No ___ Yes ___
Describe: ____________________________________
e. Indigestion: No ___ Yes ___
Describe: ____________________________________
11. Would you describe your usual lifestyle as: Active ___
Sedate ___
For breastfeeding mothers only:
12. Do you have any concerns about breastfeeding? No ___
Yes ___ Describe: ________________________________
13. Are you having any problems with breast feeding? No ___
Yes ___ Describe: ________________________________
Elimination Pattern
Objective
1. Auscultate abdomen
a. Bowel sounds: Normal ___ Increased ___
Decreased ___ Absent ___
2. Palpate abdomen
a. Tender: No ___ Yes ___ Where? _________________
b. Soft: No ___ Yes ___; Firm: No ___ Yes ___
c. Masses: No ___ Yes ___ Describe: ________________
d. Distention (include distended bladder):
No ___ Yes ___
Describe: _______________________________
e. Overflow urine when bladder is palpated?
Yes ___ No ___
3. Rectal exam
a. Sphincter tone: Describe: _______________________
b. Hemorrhoids: No ___ Yes ___
Describe: ____________________________________
c. Stool in rectum: No ___ Yes ___
Describe: ____________________________________
d. Impaction: No ___ Yes ___
Describe: ____________________________________
e. Occult in blood: No ___ Yes ___
Location: ____________________________________
4. Ostomy present: No ___ Yes ___
Location: _______________________________________
Subjective
1. What is your usual frequency of bowel movements?
a. Have to strain to have bowel movements?
Yes ___ No ___
b. Same time each day? Yes ___ No ___
2. Has the number of bowel movements changed in the past
week? No ___ Yes ___ Increased ___ Decreased ___
3. Character of stool
a. Consistency: Hard ___ Soft ___ Liquid ___
b. Color: Brown __ Black __ Yellow __ Clay-colored __
c. Bleeding with bowel movements: No ___ Yes ___
4. History of constipation: No ___ Yes ___ How often? _____
Do you use bowel movement aids (laxatives,
suppositories, diet)? No ___ Yes ___
Describe: _______________________________________
5. History of diarrhea: No ___ Yes ___ When? ____________
6. History of incontinence: No ___ Yes ___ Related to
increased abdominal pressure (coughing, laughing,
sneezing)? No ___ Yes ___
7. History of travel: No ___ Yes ___
Where and when? ________________________________
8. Usual voiding pattern
a. Frequency (times per day) _____; Decreased ___
Increased ___
b. Change in awareness of need to void: No ___ Yes ___
Increased ___ Decreased ___
c. Change in urge to void: No ___ Yes ___ Increased ___
Decreased ___
 d. Any change in amount? No ___ Yes ___ Increased ___
Decreased ___
e. Color: Yellow ___ Smokey ___ Dark ___
f. Incontinence: No ___ Yes ___ When?
____________________________________________
Difficulty holding voiding when urge to void develops?
No ___ Yes ___
Have time to get to bathroom? Yes ___ No ___; How
often does problem reaching bathroom occur?
____________________________________________
g. Retention: No ___ Yes ___
Describe: ____________________________________
h. Pain/ burning: No ___ Yes ___
Describe: ____________________________________
i. Sensation of bladder spasms: No ___ Yes ___
When? ______________________________________
Activity- Exercise Pattern
Objective
1. Cardiovascular
a. Cyanosis: No ___ Yes ___ Where? ________________
b. Pulses easily palpable?
Caroid: Yes ___ No ___; Jugular: Yes ___ No___;
Temporal: Yes ___ No ___; Femoral: Yes ___ No ___;
Popliteal: Yes ___ No ___; Poslibial: Yes ___ No ___;
Dorsalis Pedis: Yes ___ No ___
c. Extremities
i. Temperature: Cold __ Cool __ Warm __ Hot __
ii. Capillary refill: Normal ___ Delayed ___
iii. Color: Pink ___ Pale ___ Cyanotic ___ Other ___
Describe: ________________________________
iv. Homan’s sign: Yes ___ No ___
v. Nails: Normal ___ Abnormal ___
Describe: ________________________________
vi. Hair distribution: Normal ___ Abnormal ___
Describe: ________________________________
vii. Claudication: No ___ Yes ___
Describe: ________________________________
d. Heart PMI location: ____________________________
i. Abnormal rhythm: No ___ Yes ___
Describe: ________________________________
ii. Abnormal sounds: No ___ Yes ___
Describe: ________________________________
2. Respiratory
a. Rate: ___
Depth: Shallow ___ Deep ___ Abdominal ___
Diaphragmatic ___
b. Have patient cough. Any sputum? No ___ Yes ___
Describe: ____________________________________
c. Fremitus: Yes ___ No ___
d. Any chest excursion? No ___ Yes ___ Equal ___
Unequal ___
e. Auscultate chest:
i. Any abnormal sounds (rales, rhonchi)?
No ___ Yes ___
Describe: ________________________________
f. Have patient walk in place for 3 minutes (if possible):
i. Any shortness of breath after activity?
No ___ Yes ___
ii. Any dyspnea? No ___ Yes ___
iii. BP after activity: _____/_____ in right/left arm
iv. Respiratory rate after activity: ________
v. Pulse rate after activity: ________
3. Musculoskeletal
a. Range of motion: Normal ___ Abnormal ___
Describe: ____________________________________
b. Gait: Normal ___ Abnormal ___
Describe: ____________________________________
c. Balance: Normal ___ Abnormal ___
Describe: ____________________________________
d. Muscle mass/strength: Normal ___ Abnormal ___
Increased ___ Decreased ___
Describe: ____________________________________
e. Hand grasp
Right: Normal ___ Decreased ___
Left: Normal ___ Decreased ___
f. Toe wiggle
Right: Normal ___ Decreased ___
Left: Normal ___ Decreased ___
g. Postural: Normal ___ Kyphosis ___ Lordosis ___
h. Deformities: No ___ Yes ___
Describe: ____________________________________
i. Missing limbs: No ___ Yes ___
Where? _____________________________________
j. Uses mobility aids (walker, crutches, etc.)?
No ___ Yes ___
Describe: ____________________________________
k. Tremors: No ___ Yes ___
Describe: ____________________________________
4. Spinal cord injury: No ___ Yes ___
Level: __________________________________________
5. Paralysis: No ___ Yes ___
Where? ________________________________________
6. Developmental Assessment: Normal ___ Abnormal ___
Describe: _______________________________________
Subjective
1. Have patient rate each are of self care scale of 0-4.
0- Completely independent
1- Requires use of equipment or device
2- Requires help from another person for assistance,
supervision or teaching
3- Requires help from another person and equipment
device
4- Dependent; does not participate in activity
Feeding ___; Bathing ___; Dressing/grooming ___;
Toileting ___; Ambulation ___; Care of home ___;
Shopping ___; Meal preparation ___; Laundry ___;
Transportation ___
2. Oxygen use at home? No ___ Yes ___
Describe: _______________________________________
3. How many pillows do you use to sleep on? ____________
4. Do you frequently experience fatigue? No ___ Yes ___
Describe: _______________________________________
5. How many stairs can you climb without experiencing any
difficulty (can be individual number or number of flights)?
_______________________________________________
6. How far can you walk without experiencing any difficulty?
_______________________________________________
7. Has assistance at home for self-care and maintenance of
home: No ___ Yes ___ Who? _______________________
If no, would you like to have or believes needs assistance:
No ___ Yes ___ With what activities? _________________
8. Occupation: _____________________________________
9. Describe your usual leisure time activities or hobbies.
_______________________________________________
_______________________________________________
10. Any complaints of weakness or lack of energy?
No ___ Yes ___
Describe: _______________________________________
11. Any difficulties in maintaining activities of daily living?
No ___ Yes ___
Describe: _______________________________________
12. Any problems with concentration? No ___ Yes ___
Describe: _______________________________________
Sleep and Rest Pattern
Subjective
1. Usual sleep habits: Hours per night ______
Naps: No ___ Yes ___, am ___ pm ___
Feel rested? Yes ___ No ___
Describe: _______________________________________
2. Any problems
a. Difficulty going to sleep: No ___ Yes ___
b. Awakening during night: No ___ Yes ___
c. Early awakening: No ___ Yes ___
d. Insomnia: No ___ Yes ___
Describe: ____________________________________
3. Methods used to promote sleep:
Medications: No ___ Yes ___
Name: _________________________________________
Warm fluids: No ___ Yes ___ What? _________________
Relaxation techniques: No ___ Yes ___
Describe: _______________________________________
Cognitive-Perceptual Pattern
Objective
1. Review sensory and mental status completed in health
perception-health management pattern.
2. Any overt signs of pain? No ___ Yes ___
Describe: _______________________________________
Subjective
1. Pain
a. Location: ____________________________________
b. Pain Scale (Intensity): __________________________
c. Radiation: No ___ Yes ___ To where? _____________
d. Timing (how often: related to any specific events):
____________________________________________
____________________________________________
e. Duration: ____________________________________
f. What was done to relieve pain at home?
____________________________________________
____________________________________________
g. When did pain begin? __________________________
2. Decision-making
a. Decision making is: Easy ___ Moderately easy ___
Moderate ___ Difficult ___
b. Inclined to make decisions: Rapidly ___ Slowly ___
Delay ___
3. Knowledge level
a. Can define what current problems is: Yes ___ No ___
b. Can restate current therapeutic regimen:
Yes ___ No ___
Self-Perception and Self-Concept Pattern
Objective
1. During this assessment, does patient appear: Calm ___
Anxious ___ Irritable ___ Withdrawn ___ Restless ___
2. Did any physiologic parameters change?
Face reddened: No ___ Yes ___
Voice volume changed: No __ Yes __ Louder __ Softer __
Voice quality changed: No ___ Yes ___ Quavering ___
Hesitation ___ Other: _____________________________
3. Body language observed: __________________________
4. Is current admission going to result in a body structure or
function change for the patient:
No ___ Yes ___ Unsure at this time ___
Subjective
1. What is your major concern at the current time?
_______________________________________________
_______________________________________________
2. Do you think this admission will cause any lifestyle
changes for you? No ___ Yes ___ What?
_______________________________________________
_______________________________________________
3. Do you think this admission will result in any body
changes for you? No ___ Yes ___ What?
_______________________________________________
_______________________________________________
4. My usual view of myself is: Positive ___ Neutral ___
Somewhat negative ___
5. Do you believe you will have any problems dealing with
your current health situation? No ___ Yes ___
Describe: _______________________________________
6. On a scale of 0-5 rank your perception of your level of
control in this situation:
_______________________________________________
_______________________________________________
7. On a scale of 0-5 rank you usual assertiveness level:
_______________________________________________
_______________________________________________
Role-Relationship Pattern
Objective
1. Speech pattern
a. Is English the patient’s native language?
Yes ___ No ___
Native language is: ____________________________
Interpreter needed? No ___ Yes ___
b. During interview have you noted any speech
problems? No ___ Yes ___
Describe: ____________________________________
2. Family interaction
a. During interview have you observed any dysfunctional
family interactions? No ___ Yes ___
Describe: ____________________________________
b. If patient is a child, is there any physical or emotional
evidence of physical or psychosocial abuse?
No ___ Yes ___
Describe: ____________________________________
Subjective
1. Does patient live alone? Yes ___ No ___
With whom? ____________________________________
2. Is patient married? Yes ___ No ___
Children: No ___ Yes ___
Age of children: __________________________________
3. How would you rate your parenting skills?
Not appropriate ___ No difficulty ___ Average ___ Some
difficulty ___
Describe: _______________________________________
4. Any losses (physical, psychological, social) in the past
year? No ___ Yes ___
Describe: _______________________________________
5. How is patient handling this loss at this time?
_______________________________________________
_______________________________________________
6. Do you believe this admission will result in any type of
loss? No ___ Yes ___
Describe: _______________________________________
7. Ask both patient and family: Do you think this admission
will cause any significant changes in the patient’s usual
family role? No ___ Yes ___
Describe: _______________________________________
8. How would you rate your usual social activities?
Very active ___ Active ___ Limited ___ None ___
9. How would you rate your comfort in social situations?
Comfortable ___ Uncomfortable ___
10. What active or jobs do you like to do?
Describe: _______________________________________
11. What activities or jobs do you dislike doing?
Describe: _______________________________________
Sexuality-Reproductive Pattern
Objective
Review admission physical exam for results of pelvic and
rectal exams. If results not documented, nurse should
perform exams. Check history to see if admission resulted
from a rape.
Subjective
Female:
1. Date of LMP: _______
Any pregnancies: Para ___ Gravida ___
Menopause: No ___ Yes ___ Year _______
2. Use of birth control measures: No ___ N/A ___ Yes ___
Type: __________________________________________
3. History of vaginal discharge, bleeding, lesions:
No ___ Yes ___
Describe: _______________________________________
4. Pap smear annually: Yes ___ No ___
Date of last pap smear: _______
5. Date of last mammogram: _________
6. History of sexually transmitted disease: No ___ Yes ___
Describe: _______________________________________
If admission is secondary to rape:
7. Is patient describing numerous physical symptoms?
No ___ Yes ___
Describe: _______________________________________
8. Is patient exhibiting numerous emotional symptoms?
No ___ Yes ___
Describe: _______________________________________
9. What has been your primary coping mechanism in
handling this rape episode?
_______________________________________________
_______________________________________________
10. Have you talked to persons from the rape crisis center?
Yes ___ No ___ If no, want you to contact them for her?
No ___ Yes ___ If yes, was this contact of assistance?
No ___ Yes ___
Male:
1. History of prostate problems? No ___ Yes ___
Describe: _______________________________________
2. History of penile discharge, bleeding, lesions:
No ___ Yes ___
Describe: _______________________________________
3. Date of last prostate exam: ________________________
4. History of sexually transmitted diseases: No ___ Yes ___
Describe: _______________________________________
Both
1. Are you experiencing any problems in sexual functioning?
No ___ Yes ___
Describe: _______________________________________
2. Are you satisfied with your sexual relationship? 3. Will this admission interfere with your plans for the
Yes ___ No ___ future? No ___ Yes ___ How? _______________________
Describe: _______________________________________ 4. Will this admission interfere with your spiritual or
3. Do you believe this admission will have any impact on religious practices?
sexual functioning? No ___ Yes ___ No ___ Yes ___ How? _____________________________
Describe: _______________________________________ 5. Any religious restrictions to care (diet, blood transfusion)?
No ___ Yes ___ Describe: __________________________
Coping-Stress Tolerance Pattern 6. Would you like to have your (pastor/rabbi/priest/hospital
Objective chaplain) contacted to visit you? No ___ Yes ___
1. Observe behavior: Are there any overt signs of stress When? _________________________________________
(crying, winging of hands, clenched fists, etc.) 7. Have your religious beliefs helped you to deal with
Describe: _______________________________________ problems in the past?
No ___ Yes ___ How? _____________________________
Subjective
1. Have you experienced any stressful or traumatic events in General
the past year in addition to this admission? 1. Is there any information we need to have that I have not
No ___ Yes ___ covered in this interview?
Describe: _______________________________________ No ___ Yes ___ Comments _________________________
2. How would you rate your usual handling of stress? 2. Do you have any questions you need to ask me
Good ___ Average ___ Poor ___ concerning your health, plan of care or this agency?
3. What is the primary way you deal with stress or No ___ Yes ___ Questions __________________________
problems? 3. What is the first problem you would like to have helped
_______________________________________________ with?
_______________________________________________ _______________________________________________
4. Have you or your family used any support or counseling _______________________________________________
groups in the past year? No ___ Yes ___
Group name: ____________________________________
Was the support group helpful? Yes ___ No ___
Additional comments: _____________________________
5. What do you believe is the primary reason behind a need
for this admission?
_______________________________________________
_______________________________________________
6. How soon, after first nothing the symptoms, did you seek
health care assistance?
_______________________________________________
_______________________________________________
7. Are you satisfied with the care you have been receiving at
home? No ___ Yes ___ Comments: __________________
8. Ask primary caregiver: What is your understanding of the
care that will be needed when the patient goes home?
_______________________________________________
_______________________________________________

Value-Belief Pattern
Objective
1. Observe behavior: Is the patient exhibiting any signs of
alterations in mood (anger, crying, withdrawal, etc.)?
Describe: _______________________________________

Subjective
1. What do you value the most? From 1-5
Family ___ Work ___ Money ___ Religion ___ Health ___
2. Satisfied with the way your life has been developing?
Yes ___ No ___ Comments _________________________