A.

Patients Profile
What is your name?/ Ano it imo
ngaran?
When is your Birthday? /Kakan-o
ka gin Anak?
How old are you?/ Pira na it imo
edad?
Nationality? Ano imo Nationality?

Where were you born?/ Diin ka

gin anak?
Where do you live? / Hain ka
naukoy yana?
What is the name of your
parents?/ Ano it ngaran hit imo
kag-anak?
Do you have any siblings?/ Mayda
ka mga kabugtu.an? Ika pira ka
haimo kabugtu.an?
What is your religion? / Ano it imo
relihiyon?
Marital Status/ Pwede
magpakiana kun mayda ka asawa
o waray?
Pira man it imo anak?
Educational level/ Ano an imo
natapos pag skwela? Ano an imo
kurso?
Are you employed?/ Mayda ka
trabaho yana?
Ngain kaman na trabaho?

B. History of Present Illness

Urgent health concern? / Ano it

imo inaabat yana?
How long have you had this
problem?/ Kakan-o man ini
nagtikang?
What are the signs and
symptoms? Ano man an imo
mga sintomas na inaabat?
Weakness/ Kun nan luluya diin
man na parte hit imo lawas?
Numbness/ Naabat kan
pamanhod? Diin man parte?
Pain/ May maulol, ngain man?
How long does the pain last?/
Kun naul-ol mga pira ka Segundo
o minuto sano nawawara?
Pain intensity- Rating scale of 1-
10/ Gano ka ul-ol it imo gin
aabat? Ha 1 ngada 10, 1 pinaka
medyo maul-olay ngan 10
pinakama ul-ulan. Para haimo
pira it pinaka maul.ol?
What patterns do you do to
make it better? Or Worse? Any
treatments? / Ano man it imo
gin hihimo para umupay it imo
pamati? O mayda ka napapansin
na imo gin hihimo na mas
napagrabe ha imo gin aabat?
Mayda ka gin tutumar? Ano man
ini hira?
How does this problem affect
you and your daily activities? /
Paano man ini nakaka apekto
haimo gin hihimo pan adlaw-
adlaw? Nakaka apekto ba ini nga
imo gin aabat ha imo pan adlaw
adlaw nga buruhaton? Kun oo
paano man?
C. Past Health History

Did you have any health

problems at birth?What was this
or were these?/ Naistoryahan
kaba han imo kag-anak o
nakasabot ka ba kun nagkaada
ka hin sakit ha imo pagkatawo
pala?
How about any childhood
illnesses?/ Han bata ka pa
nahihinumdom kaba kun
nagkasakit ka?
What were the immunizations
you had? / Ano an mga gin
bakuna ha imo? Ano ini hira?
BCG? Hep. B? DPT? OPV?
Measles? Covid-19?
Health problems as an adult?/
Yana na may edad kana, nag
kaada kana ba hin problema ha
panlawas?
Did you have any surgeries? If
yes, on what specific part,
reason? /Naoperahan ka na?
Kuno o ngain man dapit? Ano
man an rason?
How about accidents? If yes,
what happened? / Na aksidente
ka na o nainjury ka na? Ano man
natabo?
Did you experience any
prolonged pain or pain patterns?
/ Nakaabat kana hin ma ul-ol
Do you have any allergies?
Mayda ka allergies? Allergies hi
ano?
Chronic medical conditions / Ano
imo sakit?
Previous hospitalizations /
Naospital ka na? Kakan-o? Kay
ano? Gaano kaiha?
Previous or Maintenance
medications/ Ano imo
gintutumar na medisina dati?
Mayda ka maintenance yana?
Date of last
examination/Medical check-up /
Kakan-o ka last na nagpacheck
up?
Dietary preferences and/or
restrictions / Ano imo mahilig
mo nga ginkakaon? Mayda ka
iginbabawal kaunon na
pagkaon?
D. Family Health History

What is the age of your

parents? / Pira man it edad hit
imo nanay ngan tatay?
If already dead, date of death?/
Kakan.o man hira namatay?
Can you remember any illnesses
from your parents or relative?
How old are they? What is the
longevity of the illness?/ Mayda
ka na hihinumdoman na sakit
han im kag-anak or imo iba na
kapamilya? Ano man ini na mga
sakit? Pira man it ira edad?
Kakan-o man hira nagkaada hini?
Cardiac Disorders (e.g. CHF, Stroke, Atherosclerosis, etc.) ( M / P ) – ________________________________________
Hypertension ( M / P ) –___________________________________________________________________________
Diabetes Mellitus ( M / P ) –________________________________________________________________________
Hematologic Disorders (e.g. Anemia, ITP, DIC, Sickle-Cell Disease, etc.) ( M / P ) –_____________________________
Kidney Disorders (e.g. CKD, Kidney stones, UTI, etc.) ( M / P ) –____________________________________________
Hepatobiliary Disorders (e.g. Cirrhosis, Fatty Liver, Gallstones, etc.) ( M / P ) –________________________________
Musculoskeletal Disorders (e.g. Arthritis, Osteoporosis, Injuries, etc.) ( M / P ) –_______________________________
Communicable Diseases (e.g. Tuberculosis, Hepatitis, Measles, Mumps, Dengue, Diptheria, Cholera, Influenza,
Varicella, etc.) ( M / P ) –___________________________________________________________________________
Cancer ( M / P ) –_________________________________________________________________________________
Previous Surgeries ( M / P ) –________________________________________________________________________
Psychiatric Disorders (e.g. Depression, Bipolar, Schizophrenia, Anorexia, etc.) ( M / P ) –________________________
Genetic/Hereditary Conditions ( M / P ) –______________________________________________________________
COVID-19 ( M / P ) – ______________________________________________________________________________
Others: –_______________________________________________________________________________________
E. Psychosocial History

Please describe what a typical

day is for you/ Para ha imo
ano it imo typical nga adlaw?
What are your daily
activites?/ Ano it imo
mgaurog na buhaton ha usa
ka adlaw?

GORDONS TYPOLOGY

Health Perception and Health Management BEFORE ADMISSION

What are your practices in maintaining healthy
lifestyle? When the patient feels sick, what
measures does he take?/ Ano man it imo mga
gin hihimo para padayunon hit kahimtang han
imo lawas?
Kun nasasakit ka, ano man it imo ginhihimo? DURING ADMISSION
Kun papapilion ka 1-10, ika napulo pinaka
maupay na panlawas, para ha imo pira

Nutrition and Metabolism BEFORE ADMISSION

What do you usually eat?
Ano tim kaurog na kinakaon?
Anon a pagkaon it imo hilig?
Pira ka kabeses na kaon ha usa ka adlaw?
Ano nga mga irimnon it im gin iinom?
Pira ka baso tim nauubos?
Hino man nagluluto iyo pagkaon?
Ano man iyo pagkaon ha aga? Udto? Gabi?
Nakakapira ka man pagssnack? Ano imo snack? DURING ADMISSION
Nainom ka bah in makahurubog na irimnon?
Kada sano? Pira ka baso?
Nasigarilyo ka? Pira ka sticks kada adlaw?
Nagamit ka ba hin drugs?

Elimination BEFORE ADMISSION

What is your urinary pattern? Estimated volume
of urine?/ Kumusta it imo pag ihi? Masukot ba o
panalagsa la? Para ha imo mga pira ka damo it
imo na iihi? An imo pag uro kumusta man? Bug-
os ba o bagat tubig?
How many times do you urinate and defecate?/ DURING ADMISSION
Ha usa ka adlaw nakaka pira kaman iihi o uuro?

Activity Exercise Pattern BEFORE ADMISSION

What is your daily activity pattern? / Ano it imo
gin hihimo na aktibidades ha pan adlaw-adlaw?
Do you exercise? What type of exercise do you
do? / Nag eehersisyo ka? Ano nga ehersisyo it
imo gin bubuhat? DURING ADMISSION
What are your leisures or recreational activities?
/ Ano it imo gin hihimo na mga pampalipas
oras?

Cognitive- Perceptual Pattern BEFORE ADMISSION

Do you have any sensory deficits? /Mayda ka
problema ha imo pagkita, panrasa, panhamot,
panbati? Kun mayda ka inaabat na maul-ol DURING ADMISSION
pwede mo iyakan kun gano hiya ka ul-ol ngan
kun mayda ka nakikita nga rason hini na
pagsakit?
Sleep-Rest Pattern BEFORE ADMISSION
Tell me about your sleeping patters/ Kumusta
man it imo pagkaturog?
Do you have problem falling asleep? /Mayda ka
problema ha pagkaturog? DURING ADMISSION
How much do you sleep at night? / Pira ka oras
it im pagkaturog ha us aka gabi?
Do you nap during the day? /How often and
how long? / Kun adlaw nakakakaturog ka?
Panalagsa b aini or pirme? Pira man ka oras?
Self Perception Pattern
How do you feel about yourself? /Kun
pakianhan ta ikaw ano man it imo mayayakan
hit imo kalugaringon?
What do you see as your talents or abilities?
Ano it imo talent?
How often do you have medical check ups?/
Kada sano ka man napakadto ha doctor pagpa
check up?
Role- Relationship Pattern
Pira kamo na magburugto? Ikapira ka?
Kaupod mo ba imo pamilya yana?
Ano trabaho nimo tatay? Nanay?
Ano gintapusan nimo mga kabugtuan?
Who is/ are the most important people in your
life. Describe your relationship with person or
people/ Para ha imo hino man pinaka
importante nga tawo ha imo kinabuhi? Pwede
mo ig istorya ha akon paano it imo relasyon ha
ira? What was it like growing with your family? /
Kumusta man an imo relasyon ha imo pamilya?
Ano man an imo responsibilidad ha imo
pamilya? Mayda kamo mga hayop? Ano man ito
hira?
Sexual- Reproductive Pattern BEFORE ADMISSION
Do you have any reproductive problems? Mayda
ka ba problema ha imo reproduction o ha imo
pagkalalaki o pagkababayi?
Is it okay to ask if you practice safe sex? How
many times? /Pwede ak magpakiana kun
nakikipaghilawas ka pa? Kun oo pira man ka
beses? Nagamit ba kamo hin contraceptive DURING ADMISSION
method?
KUN BABAYE: Kakan-o nim syahan nga regla?
Kada bulan ka gin reregla o layagan ka? Kun gin
reregla ka nakakapira man ka adlaw? Pira ka
pads imo nagagamit ha usa ka adlaw
Coping and Stress Tolerance Pattern BEFORE ADMISSION
How would you describe your level of stress? /
Madali ka ba ma stress or diri? Pag na stress ka
ano man it imo binubuhat?
Para ha imo ano it pinaka nakaka hatag hin
stress haimo?
Ngain o kan kanay ka man nakadto kun nagkaka DURING ADMISSION
ada ka hin problema?
Nag aano ka man kun nasstress ka?
Mayda ka ba traumatic na experience?

Values and Belief Pattern

What is the most important to you in life? / Ano
it pinaka importante ha imo kinabuhi?
Do you have religious affiliation? Is it important
to you? Mayda ka gin tutuo nga relihiyon? Ano
ini ka importante ha imo?
Para ha imo importante ba magkaada hin
maupay nga relasyon ha ginoo o haimo gin
tutuohan?
What gives you strength or hope? / Ano man it
nahatag haimo hin kusog o paglaom?