Questionnaire
Geriatric Wellness State using the 11 Gordon's Functional Health Pattern: A Basis for Community Activity
Program
Demographic Profile
Age:
Sex:
Civil Status:
Family Structure:
Comorbidities:
Direction:
Section I: Health Perception and Health Management Pattern
1. How would you rate your overall health?
Excellent
Very Good
Good
Fair
Poor
2. What do you do to stay healthy?
3. How often do you visit your healthcare provider?
Weekly
Monthly
Every few months
Yearly
Only when necessary
4. What types of health issues are you currently managing, if any?
5. How do you manage your health and wellness on a daily basis?
Section II: Nutritional and Metabolic Pattern
1. Can you describe what you typically eat in a day's meals and snacks?
2. Do you have any dietary restriction or special dietary needs?
3. How often do you eat fruits and vegetables in a day?
Multiple times
Once a day
Few times a week
Rarely
4. Do you have any food allergy?
5. What foods do you believe are important for maintaining good health?
6. Are you currently taking any supplements or vitamins?
Section III: Elimination Pattern
1. Do you experience any difficulties with urination or bowel movements? Please describe.
2. How often do you have bowel movements? (Inclusion: Frequency, Color, Amount, Odor)
Daily
Every other day
Few times a week
Less often
3. Have you noticed any changes in your elimination patterns recently?
4. Are you using any laxatives? If yes, which?
Section IV: Activity and Exercise Pattern
1. Do you have breathing problems?
2. What types of physical activities do you engage in regularly?
3. How often do you exercise each week?
4. Do you have any concerns or limitations that affect you ability yo physically active?
Section V: Sleep and Rest Pattern
1. How many hours of sleep do you typically get at night?
2. Do you have any difficulties falling or staying asleep?
3. How do you feel upon waking up in the morning?
4. Are there any factors that affect your sleep quality? (e.g., noise, discomfort)
Section VI: Cognition and Perception Pattern
1. How do you feel about your memory and ability to think clearly?
2. Have you experienced any changes in vision or hearing?
3. How do you keep your mind active and engaged?
Section VII: Self-Perception and Self-Concept Pattern
1. How would you describe your self-esteem and body image?
2. Have there been any recent changes in how you view yourself?
3. Do you like grooming?
4. What activities or hobbies make you feel good about yourself?
Section VIII : Roles and Relationship Pattern
1. Who do you consider to be your primary support system?
2. Who is the decision maker in the family?
3. How often do you interact with your family and friends?
4. How do you maintain relationships with your family and friends?
5. Are you involved in any community or social groups?
Section IX: Sexuality and Reproduction Pattern
1. Are there any issues related to sexuality or intimacy that you would like to discuss?
2. How have your attitudes towards intimacy or relationship evolved with age?
3. Are you sexually active?
Section X: Coping and Stress Tolerance Pattern
1. How do you typically manage stress in your life?
2. Are there any significant stressors currently affecting your life?
3. What strategies do you use to manage stress?
Section XI: Value and Belief Pattern
1. What is your religion?
2. What do you believe is important for maintaining good health?
3. What are your core values and beliefs?
4. How do these values and beliefs influence your daily life and decisions?
5. Are there any cultural or spiritual beliefs that influence your health behaviors?
Additional:
1. What is your primary health and wellnes goal?
2. Are there any community activities or programs that would you like yo see implemented to support
your wellnes?
