GORDON’S ASSESSMENT GUIDE QUESTIONS
1.Health Perception/Health Management Pattern
Hospitalized Client
1) Reason for admission:
2) What is your understanding of the purpose of the treatment? How do you think the treatment
is working?
3) Have you ever been hospitalized before? For what reason/s?
4) What expectations do you have about this hospitalization?
2.Nutritional/Metabolic Pattern
Record the diet by a recall of ALL food and beverages taken over the last 24 hours. “Is that
menu typical of most days?”Describe eating habits and current appetite. Ask, “Who buys and
prepares the food?” “Are your finances adequate for food?” “Who is present at mealtime?”
Indicate any food allergy or intolerance. Record the daily intake of caffeinated beverages.
1) How is your appetite?
2) Describe what you eat in a typical day.
3) Do you have food restrictions or special diet due to allergies, food intolerance, religious
practices, or other health problems?
4) What vitamins or supplements do you take?
5) What are your food preferences? Likes and dislikes?
6) How often do you go to fast food restaurants?
7) Do you experience any discomfort in eating or swallowing?
8) Do you have dental problems?
9) Describe your daily fluid intake.
3.Elimination Pattern
1) What is your regular bowel movement pattern?
2) Which of the following do you experience? _____ Constipation _____ Diarrhea _____
Ostomy
3) How is your urinary elimination pattern?
4) Which of the following do you experience? _ Incontinence _ Dysuria _ Burning sensation
_ Dribbling _Nocturia _ Oliguria _Polyuria _Urinary retention _Catheter present
5) Urine color: __________
6) Do you have any of the following skin problems? _Dryness _ Poor skin turgor _ Rashes
_ Lesions _Swelling _Acne _ Temperature change
7) Do you experience excess perspiration and odor problems?
4.Activity and Exercise Pattern
This reflects usual daily activities. Ask, “Tell me how you spend a typical day?” Note ability to
perform ADLs: independent or needs assistance with feeding, bathing, hygiene, dressing,
toileting, bed to chair transfer, walking, standing, or climbing stairs? Any use of wheelchair,
prostheses, or mobility aids? Record also leisure activities enjoyed and exercise pattern (type,
amount per day/week, method of warm-up session, method of monitoring the body’s response
to exercise).
1) Describe a typical day’s activity.
2) What are your usual leisure activities?
3) Do you have regular exercise pattern? Type? Frequency? Intensity? Duration?
4) Describe any problem you have experienced with usual activity and exercise?
5) Do you experience the following: Chest Pain? _ Arm Pain? _ Leg Pain? _Back Pain? _
Difficulty in breathing (dyspnea, wheezing, orthopnea)? _ Cough? _ Tingling/Numbness? _
Lightheadedness? __ Fatigue/Weakness? __ Palpitations? _
6) Factors affecting activity tolerance: Do you smoke? _ If YES, what are the estimated packs
per year? _____
5.Sleep/Rest Pattern
1)Time of arising? _ Time of retiring? _ Do you take naps? _ If YES, how long? _How often?
2) In general, do you feel well-rested and ready for daily activities after sleeping? _____
3) Do you have aids to help you sleep? _____ If YES, what? _____
4) Do you have dreams or nightmares? _____ If YES, what kind? _____
5) Do you experience insomnia? _____ If YES, how often?
Personal Habits
A. Tobacco
1)Do you smoke cigarettes (pipe, use chewing tobacco)? _____
2)At what age did you start smoking? _____
3)How many packs do you smoke per day? _____
4)How many years have you smoked? _____ (record number of packs smoked per day [PPD]
and duration, example: 1 PPD x 5 years)
5)Have you ever tried to quit? _____
6)How did it go? _____
B. Alcohol
1)Do you drink alcohol? _____
2)When was your last drink of alcohol? _____
3)How much did you drink that time? _____
4)Out of the last 30 days, about how many days would you say that you drank alcohol? _____
5)Have you ever had a drinking problem? _____
6)CAGE (cut down, annoyed, guilty, eye-opener) questions:
a.Have you ever thought you should cut down your drinking? _____
b.Have you ever been annoyed by criticism of your drinking? _____
c.Have you ever felt guilty about your drinking? _____
d.Do you drink in the morning? _____
* If person answers YES to 2 or more CAGE questions, suspect alcohol abuse
7)If patient answers NO to drinking alcohol:
a.What are your reasons for this decision? _____
b.Any history of alcohol treatment? _____
c. Are you involved in recovery activities? _____
d.Do you have a family member with a problem in drinking?
C. Street Drugs
1)Which of these drugs have you taken or are currently taking? _marijuana _ cocaine
_methampethamine (shabu) _ barbiturates/depressants
2) How often do you take these? _____
3) Has your use affected your work or your family? _____
6.Cognitive and Perceptual Pattern
1)Eyes and vision last examination result? _ Do you wear glasses/contact lenses? _ Do you
experienceblurring? _ Diplopia? _ Pain? _ Inflammation? _ Cataract? _ Glaucoma? _
Headache? _ Photophobia? _ Unusual discharges? _ Describe them: ____
2) Ears and hearing limitations: Pain? _____ Tinnitus? _____ Describe discharges: ____
3) Other special senses: any problems with
ability to feel pain? _ ability to feel temperature changes? _
ability to distinguish object by touch? _ability to smell? _ ability to taste? __
4) Pain: are you experiencing pain? ___ if YES, describe the location: _____ type: _____ How
does the pain affect your daily activities?
7.Self-Perception Pattern
1) How do you feel about yourself most of the time?
2) Is there something about yourself or your appearance that you like to change?
3) How does your illness affect the way you feel about yourself or your body? __
4) What things make you anxious? ____Fearful? _____Distressed? ________
5) What do you do to alleviate your feelings?
8. Role-Relationship Pattern
1)Who do you live with? _
2) Describe your family structure. _
3) Do you get along with your family? _with your friends? _____ with your co-workers? _____
4) Who do you turn to for help? ____
5) Do family members depend on you? __ How are they managing while you’re ill? __
6) How would you describe your role in the family?
7) How has your health status affected your relationship with others? _
8) What feelings have family members and friends expressed about your illness and
hospitalization?
9.Sexuality and Reproduction Pattern
1) Is your sexual relationship satisfying? _ Have any changes or problems taken place with
these relationships?
2) Do you take contraceptives? _ Have you had any problems with using contraceptives? __
3) When was your last menstrual period? _____
4) Do you have any of the following problems: amenorrhea _ dysmenorrhea _ profuse bleeding_
irregular menstruation_
5) When was your last pap smear? _____ how often do you undergo pap smear? _____
6) Do you perform breast self-examination? _____
7) Do you have children? ___ if YES, describe your complaints: __________
8) Are you currently pregnant? _____
9) Do you perform testicular examination? _____
10) Do you have prostate problems? _____ if YES, describe your complaints: __
11) Have you ever had infections of the reproductive tract? __ if YES, what are they?
10.Coping and Stress Management Pattern
1)What major changes/losses have you experienced in the past year? _____
2) Situations that cause stress in the past? __
3) Situations that case stress in the present? ___
4) How do stressful situations affect you?
5) How do you usually solve your problems? __
6) How do you relieve tension and deal with stress? _
7) Who do you turn to for help during personal crisis? _
8) Are you able to handle problems successfully most of the time. _
11.Value and Belief Pattern
1) What are the most important things to you? ___
2) Do you generally get what you want in life? __
3) What are your plans for the future? __
4) Do you find prayer and meditations helpful? _
5) Has being sick affected your belief and your religion with God: __
6)Use FICA questions to incorporate the person’s spiritual values into the health history:
a.Faith: Does religious faith or spirituality play an important role in your life? Do you consider
yourself a religious or spiritual person? _____
b.Influence: How does your religious faith or spirituality influence the way you think about your
health or the way you care for yourself? _____
c.Community: Are you part of any religious or spiritual community or congregation? _____
d.Address: Would you like me to address any religious or spiritual issues or concerns with you?
