Gordons 11 Functional Health Patterns Assessment Questions

1. Health Perception-Health Management Pattern a. In general, how is the familys health? b. What do you do to stay healthy? Do you drink alcohol or use tobacco products? c. Do you have regular check-ups with your physician and/or specialists (Pediatrician, Ob/Gyn, Cardiologist, etc.)? Do you listen to and follow any suggestions made by your health care providers? 2. Nutritional-Metabolic Pattern a. Describe your Familys typical daily food intake? Do you consider your family healthy eaters? b. Describe your familys typical daily fluid intake? Do you drink alcohol? c. Does anyone consider themself over or under weight? Is there any unexplained weight gain or loss? 3. Elimination Pattern a. Describe your familys regular bowel elimination pattern? Frequency? Character? Discomfort? Difficulty? b. Describe your familys regular urinary elimination pattern? Frequency? Discomfort? Problems with control? 4. Activity-Exercise Pattern a. Do you exercise? What type? How often? If not, why? b. What do you like to do in your spare time? What sports do you participate in? 5. Sleep-Rest Pattern a. Do you feel that you are generally well rested and able to perform your daily activities? b. How well do you fall asleep? Stay asleep? Do you use any aids to help you sleep? c. Do you awaken feeling rested and ready to take on the day? 6. Cognitive-Perceptual Pattern a. Does anyone have any difficulty hearing others? b. Does anyone have difficulty seeing? Do you have routine eye exams? c. How do you learn best? Preference for visual or audio aids? Do you have difficulty learning? 7. Self-Perception Self-Concept Pattern a. Most of the time, do you feel good about yourself? b. Do you ever feel that you have lost hope?

8. Roles-Relationships Pattern a. Who do you live with? Alone, family, others? What was the structure in which you grew up? b. Do you belong to social groups? Do you interact with others outside of work or school? 9. Sexuality-Reproductive Pattern a. Parents: How would you describe your sexual relationship? Satisfying? Changes? Problems? b. Female: Describe menstruation cycle. Problems? Last menstrual period? Para? Gravida? 10. Coping-Stress Tolerance Pattern a. Any big changes in the past year or two? b. Who is most helpful in talking things over? Are the frequently available to you? c. Do you use any medications, drugs, or alcohol? 11. Values-Beliefs Pattern a. Is religion important in your familys life? Does this help when you are faced with difficult situations? b. Describe your plans for the future. Do you generally get what you want from life?