GORDON’S FUNCTIONAL HEALTH PATTERN

NAME: SEX:
ADDRESS: CIVIL STATUS:
CITIZENSHIP: RELIGION:
AGE: B-DATE:
OCCUPATION: B-PLACE:
WARD:
CASE NO.:
IMPRESSIONS:

CURRENT HEALTH STATUS

Chief complaint/s:
a. Reason for seeking health care.
b. What has the doctor told you regarding your health?
c. Describe the medication you have received.

PAST MEDICAL HISTORY

a. Tell me any about past illnesses surgeries you have had?
b. Have you had other illnesses in the past? Specify?
c. How were the past illnesses treated?
d. Have you ever been in the hospital before?
e. How did you feel about your past history stay?
f. Are you allergic to any drugs, foods, or other environment substances (dust, mold, pollens)?
g. Describe the reaction you have when exposed to the allergic substances.
h. What do you do for your allergies?

FAMILY HISTORY
a. Describe your family.
b. Do you live with your family or alone?
c. How does your family get along?
d. Who makes the major decisions in your family?
e. Who is the main financial supporter of your family?
f. What is your major responsibility in your family? How do you feel this responsibility?
g. How does your family deal with problems?
h. Are there any major problems now?
i. Who is the person you feel closest to in your family? Explain.
j. How is your family coping with your current state of health?

GENOGRAM (SKETCH THE GENOGRAM)

LEGEND:
FEMALE: 0
MALE:
TWINS: 0=0
DECEASED: /
CAUSE OF DEATH UNKNOWN: ?
CLIENT:
MARRIAGE: _____________
DIVORCE: ______X______
LIVING TOGETHER (NOT MARRIED): ------
OFFSPRING: I
ADOPTED CHILD:
ALIVE AND WELL: A&W
SLEEP-REST PATTERN
a. Describe your usual sleeping pattern at home?
b. How would you rate the quality of your sleep?
c. Do you ever experience difficulty with falling asleep?
d. Has your current health altered your normal sleep habits?
e. What helps you fall asleep?

ACTIVITY AND EXERCISE

A. ACTIVITY OF DAILY LIVING
a. Describe your activities on a normal day (including hygiene)
b. Does your current physical health affect any of these self-care activities?

B. EXERCISE ROUTINE
a. Describe the activities that you feel give you exercise.
b. How often are you able to do this type of exercise?
c. Has your health interfered with your exercise?

C. OCCUPATIONAL ACTIVITIES
a. Describe what you do to make a living?
b. How has your health affected your ability to work?

COGNITIVE AND PERCEPTION PATTERN

A. ABILITY TO UNDERSTAND
a. Explain what your doctor has told about your health?
b. What is the best way to learn something new (read, watch tv, etc.)

B. ABILITY TO COMMUNICATE
a. Can you tell how you feel about your health?
b. Do you ever have difficulty expressing yourself or explaining things to others?

C. ABILITY TO REMEMBER
a. Are you able to remember recent events and events of long ago?

D. ABILITY TO MAKE DECISIONS

a. Describe how you feel when faced with a decision?
b. Do you find decision making difficult, fairly easy, or variable?

SELF-PERCEPTION AND SELF CONCEPT PATTERN

a. Describe yourself
b. What do you consider to be your strength? Weakness?
c. How do you feel about yourself?
d. How does your family feel about you and your illness?
e. How do you feel about your appearance?
f. How do you feel about other people with disabilities?

ROLES AND RELATIONSHIP PATTERN

a. Describe your occupation
b. What is your major responsibilities at work?
c. How do you feel about those you work with?
d. Are there any major problems you have at work?
e. Who is the most important person in your life? Explain.
f. Describe your neighbourhood and the community in which you live.
g. Do you participate in any social groups or neighbourhood activities?
h. What do you see as your contribution to society?
HEALTH PERCEPTION & HEALTH MANAGEMENT
a. Describe your health.
b. How would you rate your health on a scale of 1 to 10, (10 is the highest and 1 is the lowest)?
c. Describe your illness or current health problem.
d. How has this affected your normal daily routines?
e. How do you feel your current daily activities affected your health?
f. What do you feel caused your illness?
g. Tell me what do you do when you have a health problem?
h. When do you seek nursing or medical advice?
i. What activities do you feel to keep you healthy?
j. Do you perform self-exams? (BSE, TSE, BP)
k. When were your last immunization?

NUTRITION AND METABOLIC PATTERN

a. Describe the type and amount of food you eat at breakfast, lunch, supper on an average
day.
b. What time do you usually eat your meals?
c. What type of snacks do you eat? How often?
d. Do you take any vitamin supplements? Describe.
e. Do you consider your diet high in fat? Sugar? Salt?
f. What kind of fluids do you usually drink?
g. Do you have difficulty chewing or swallowing food?
h. When was your last dental exam?
i. Do you ever experience sore throats, sore tongue, or sore gums?
j. Do you ever experience nausea and vomiting
k. Do you ever experience abdominal pains?
l. Do you use antacids?

BLADDER ELIMINATION METHOD

a. Describe your urinary habit.
b. How frequent do you urinate?
c. What is the amount and color of your urine?
d. Do you have any of the following problems with urinating?
- Pain
- Blood urine
- Difficulty starting a stream
- Incontinence
- Voiding frequently at night
- Voiding frequently at day
- Bladder infection
e. Have you ever had bladder surgery? Describe.
f. Have you ever had a urinary catheter? Describe.

BOWEL ELIMINATION PATTERN

a. Describe your bowel pattern. Have there been any recent changes?
b. How frequent are your bowel movement?
c. What is the color and consistency of your stool?
d. Do you use laxatives? What kind and how often do you use them?
e. Do you use enemas? How often and what kind?
f. Do you use suppositories? How often and what kind?
g. Do you have any discomfort with your bowel movement? Describe.
COPING AND STRESS TOLERANCE PATTER
a. Describe what you believe to be the most stressful situations in your life.
b. How has your illness affected the stress you feel?
c. Has there been a personal loss or major change in your life over the last year? Explain.
d. What has helped you to cope with this change or loss.
e. What do you usually do first when faced with a problem?
f. What helps you to relieve stress and tension?
g. To whom do you usually turn when you have a problem or feel under pressure?
h. How do you usually deal with problem?

SEXUALITY AND REPRODUCTIVE PATTERN

A. FEMALE
a. Menstrual History
 How old were you when you began menstruating?
 How many days does your cycle last?
 Do you experience pain, mood changes, flushing, chilling, or any discomfort
before, during, or after menstruation?

b. Obstetric history
 How many times have you been pregnant?
 Describe the outcome of each of your pregnancies?
 Number of children, indicate the age, sex of each child.

c. If pregnant:
 Was this a planned or unexpected pregnancy?
 Describe your feelings about this pregnancy.
 What changes in your lifestyle do you anticipate with this pregnancy?
 Describe any difficulties or discomfort you have had with this pregnancy.

B. MALE
a. Contraception
 What contraceptive do you use to prevent pregnancy?
 Does this means of birth control affect your enjoyment of sexual relations?
b. Sexual activities
 Describe your level of satisfaction from your sexual relation.
 Describe any pain or discomfort you have during intercourse.
 Have you experienced difficulty achieving orgasm or maintaining an
erection?
 Do you have had a sexually transmitted disease?
 What methods do you use to prevent contracting STD’s?
 Describe any discharge or unusual odor you have often from your penis.
 Describe any pain, burning, or discomfort you have while voiding.
c. History of sexual abuse
 Describe the time & place the incident occurred.
 Explain the type of sexual contact that occurred.
 Describe the person who assaulted you.
 Identify any witness present.
 Describe your feelings about this incidence.
 Have you had any difficulty sleeping, eating, or working since the incident
occurred?

VALUE AND BELIEF PATTERN

a. What is most important to you in your life?
b. What do you hope to accomplish in life?
c. What is your major source of hope and strength in life?
d. Do you have a religious affiliation?
e. Is this important to you?
f. Are there certain practices (prayer, reading scripture) that are important to you?