St.
Scholastica’s College Tacloban
Maharlika Highway, Brgy. Campetic, Palo, Leyte
College of Nursing.
A.Y. 2024-2025
I. HEALTH HISTORY
Do you have any chronic illnesses?
had any major surgeries or hospitalizations? If yes, state chuchu
Have you had any serious infections or diseases?
Are you currently taking any medications or supplements?
Does anyone in your family have a history of heart disease, diabetes, hypertension, or
cancer?
Are there any genetic disorders in your family?
Do you smoke, drink alcohol, or use drugs?
What is your diet like?
How often do you exercise?
Do you experience stress or anxiety?
Do you have any allergies to medications, food, or the environment?
Are you up to date with your vaccination?
II. PHYSICAL ASSESSMENT
Do you feel any discomfort or pain right now?
Have you noticed any recent weight loss or gain?
Do you feel fatigued or weak
III. GORDON’S TYPOLOGY
Health Perception–Health Management Pattern
How would you describe your current health?
Do you have any chronic illnesses or past major health problems?
Do you visit a healthcare provider regularly?
What medications are you currently taking?
Are you up to date with your vaccinations?
Do you use tobacco, alcohol, or any substances?
Have you ever delayed or avoided seeking medical care?
Do you follow any health-related routines (e.g., check-ups, self-exams)?
Do you understand your current health conditions?
Who helps you make decisions about your health?
Nutritional–Metabolic Pattern
Can you describe a typical day’s meals?
Do you have any special diet or food restrictions?
Have you noticed any weight changes recently?
Do you have trouble chewing or swallowing?
Do you take any vitamins or supplements?
How much water do you drink daily?
Do you feel full quickly or have a poor appetite?
Have you had nausea, vomiting, or diarrhea?
Do you have any food allergies or intolerances?
Elimination Pattern
How often do you have a bowel movement?
Have you experienced constipation or diarrhea?
Do you have any trouble urinating (frequency, urgency, pain)?
Do you use any aids for elimination (e.g., catheter, laxatives)?
Do you ever have urinary incontinence?
Do you notice any blood in your stool or urine?
How would you describe your urine and stool color?
Do you feel completely emptied after urinating or defecating?
Have you had any recent urinary tract infections?
Are you on any medications that affect elimination?
Activity–Exercise Pattern
What is your usual daily physical activity?
Do you exercise regularly?
Do you get tired easily?
Do you need assistance with daily activities (e.g., bathing, walking)?
Do you use any mobility aids (e.g., cane, walker)?
Have you experienced shortness of breath during activity?
Do you have joint or muscle pain that limits movement?
Do you participate in recreational activities or sports?
Do you feel your energy level is adequate?
Have you had any recent falls or injuries?
Sleep–Rest Pattern
How many hours do you sleep per night?
Do you have difficulty falling or staying asleep?
Do you take any medications or supplements to help with sleep?
Do you feel well-rested upon waking?
Do you nap during the day?
Do you have any sleep-related conditions (e.g., sleep apnea, insomnia)?
Do you snore loudly or wake up gasping for air?
Do you wake up frequently to urinate?
How many pillows do you sleep with?
Do you have any nighttime routines to help you sleep?
Cognitive–Perceptual Pattern
Have you noticed any changes in your memory or concentration?
Do you have trouble understanding or expressing thoughts?
Do you experience confusion or disorientation?
Do you use glasses or hearing aids?
Do you have pain, numbness, or tingling sensations?
Have you had problems with your vision or hearing?
Do you experience dizziness or fainting?
Do you have difficulty making decisions?
Do you ever see or hear things that others don’t?
Have you had any recent head injuries?
Self-Perception–Self-Concept Pattern
How would you describe yourself?
Are you satisfied with your physical appearance?
Do you feel confident about your abilities?
Have you had any recent changes in body image (e.g., illness, surgery)?
Do you feel anxious or depressed?
How do you cope with stress?
Do you feel in control of your life?
Do you have someone to talk to about personal concerns?
Have you ever been diagnosed with a mental health condition?
Do you feel safe and secure in your daily life?
Role–Relationship Pattern
Who lives with you at home?
What is your role in the family or community?
Are your relationships with family and friends supportive?
Do you have someone who can help you when you are ill?
Have you had any recent losses or changes in relationships?
Do you feel socially isolated or lonely?
Are there conflicts in your personal or professional life?
Do you have children or dependents you care for?
Are you involved in any community or religious groups?
9. Sexuality–Reproductive Pattern
Are you sexually active?
Do you use any method of contraception?
Do you have any concerns regarding sexual performance or desire?
Have you experienced any changes in sexual function?
Do you have any pain during intercourse?
Have you ever been diagnosed with an STD?
Are you satisfied with your current sexual relationships?
For women: Are your menstrual cycles regular?
For men: Do you have any issues with erections or ejaculation?
Do you feel safe in your sexual relationships?
Coping–Stress Tolerance Pattern
What causes you stress on a daily basis?
How do you usually deal with stress?
Do you feel overwhelmed or anxious often?
Have you experienced a major life change recently?
Do you use any relaxation techniques (e.g., prayer, meditation)?
Do you have emotional support from family or friends?
Do you turn to substances when stressed?
Have you had thoughts of harming yourself or others?
How well do you adapt to change?
Do you think your current coping methods are effective?
Value-Belief
Do you have any religious or spiritual beliefs that are important to you?
How do your beliefs or values influence your decisions about health and illness?
Are there any cultural or spiritual practices you follow regularly (e.g., prayer, rituals)?
In times of stress or illness, where do you usually turn for comfort or support?
Would you like your health care providers to consider your spiritual or religious beliefs in
your care?
St. Scholastica’s College Tacloban
Maharlika Highway, Brgy. Campetic, Palo, Leyte
College of Nursing.
A.Y. 2024-2025
I. HEALTH HISTORY
Do you have any chronic illnesses?
(May-ada ka ba ginbabati nga maluya o grabe nga sakit ha lawas?)
High blood
had any major surgeries or hospitalizations? If yes, state chuchu. Waray pa
Have you had any serious infections or diseases?
Are you currently taking any medications or supplements?
Does anyone in your family have a history of heart disease, diabetes, hypertension, or
cancer?
Are there any genetic disorders in your family?
Do you smoke, drink alcohol, or use drugs?
What is your diet like?
How often do you exercise?
Do you experience stress or anxiety?
Do you have any allergies to medications, food, or the environment?
Are you up to date with your vaccination?
II. PHYSICAL ASSESSMENT
Do you feel any discomfort or pain right now?
Have you noticed any recent weight loss or gain?
Do you feel fatigued or weak
III. GORDON’S TYPOLOGY
Health Perception–Health Management Pattern
How would you describe your current health?
Do you have any chronic illnesses or past major health problems?
Do you visit a healthcare provider regularly?
What medications are you currently taking?
Are you up to date with your vaccinations?
Do you use tobacco, alcohol, or any substances?
Have you ever delayed or avoided seeking medical care?
Do you follow any health-related routines (e.g., check-ups, self-exams)?
Do you understand your current health conditions?
Who helps you make decisions about your health?
Nutritional–Metabolic Pattern
Can you describe a typical day’s meals?
Do you have any special diet or food restrictions?
Have you noticed any weight changes recently?
Do you have trouble chewing or swallowing?
Do you take any vitamins or supplements?
How much water do you drink daily?
Do you feel full quickly or have a poor appetite?
Have you had nausea, vomiting, or diarrhea?
Do you have any food allergies or intolerances?
Elimination Pattern
How often do you have a bowel movement?
Have you experienced constipation or diarrhea?
Do you have any trouble urinating (frequency, urgency, pain)?
Do you use any aids for elimination (e.g., catheter, laxatives)?
Do you ever have urinary incontinence?
Do you notice any blood in your stool or urine?
How would you describe your urine and stool color?
Do you feel completely emptied after urinating or defecating?
Have you had any recent urinary tract infections?
Are you on any medications that affect elimination?
Activity–Exercise Pattern
What is your usual daily physical activity?
Do you exercise regularly?
Do you get tired easily?
Do you need assistance with daily activities (e.g., bathing, walking)?
Do you use any mobility aids (e.g., cane, walker)?
Have you experienced shortness of breath during activity?
Do you have joint or muscle pain that limits movement?
Do you participate in recreational activities or sports?
Do you feel your energy level is adequate?
Have you had any recent falls or injuries?
Sleep–Rest Pattern
How many hours do you sleep per night?
Do you have difficulty falling or staying asleep?
Do you take any medications or supplements to help with sleep?
Do you feel well-rested upon waking?
Do you nap during the day?
Do you have any sleep-related conditions (e.g., sleep apnea, insomnia)?
Do you snore loudly or wake up gasping for air?
Do you wake up frequently to urinate?
How many pillows do you sleep with?
Do you have any nighttime routines to help you sleep?
Cognitive–Perceptual Pattern
Have you noticed any changes in your memory or concentration?
Do you have trouble understanding or expressing thoughts?
Do you experience confusion or disorientation?
Do you use glasses or hearing aids?
Do you have pain, numbness, or tingling sensations?
Have you had problems with your vision or hearing?
Do you experience dizziness or fainting?
Do you have difficulty making decisions?
Do you ever see or hear things that others don’t?
Have you had any recent head injuries?
Self-Perception–Self-Concept Pattern
How would you describe yourself?
Are you satisfied with your physical appearance?
Do you feel confident about your abilities?
Have you had any recent changes in body image (e.g., illness, surgery)?
Do you feel anxious or depressed?
How do you cope with stress?
Do you feel in control of your life?
Do you have someone to talk to about personal concerns?
Have you ever been diagnosed with a mental health condition?
Do you feel safe and secure in your daily life?
Role–Relationship Pattern
Who lives with you at home?
What is your role in the family or community?
Are your relationships with family and friends supportive?
Do you have someone who can help you when you are ill?
Have you had any recent losses or changes in relationships?
Do you feel socially isolated or lonely?
Are there conflicts in your personal or professional life?
Do you have children or dependents you care for?
Are you involved in any community or religious groups?
9. Sexuality–Reproductive Pattern
Are you sexually active?
Do you use any method of contraception?
Do you have any concerns regarding sexual performance or desire?
Have you experienced any changes in sexual function?
Do you have any pain during intercourse?
Have you ever been diagnosed with an STD?
Are you satisfied with your current sexual relationships?
For women: Are your menstrual cycles regular?
For men: Do you have any issues with erections or ejaculation?
Do you feel safe in your sexual relationships?
Coping–Stress Tolerance Pattern
What causes you stress on a daily basis?
How do you usually deal with stress?
Do you feel overwhelmed or anxious often?
Have you experienced a major life change recently?
Do you use any relaxation techniques (e.g., prayer, meditation)?
Do you have emotional support from family or friends?
Do you turn to substances when stressed?
Have you had thoughts of harming yourself or others?
How well do you adapt to change?
Do you think your current coping methods are effective?
