GORDON’S FUNCTIONAL HEALTH PATTERN

A. PATTERN OF HEALTH PERCEPTION AND HEALTH MANAGEMENT

STATEMENT OF THE PROBLEM PRIOR TO ADMISSION DURING HOSPITALIZATION SIGNIFICANCE PROBLEM IDENTIFIED
1. How do you describe your
current health?

2. What do you do to
improve or maintain your
health?
ADL / INDEPENDENT/
DEPENDENT (level):
Preferred time for
personal care / bath:
Assistance required /
provided by:

3. How do you link lifestyle

choices and health?

4. How big is the problem in

financing health care for
you?

5. Can you name current

medications you are
taking and their purpose?

6. Do you have allergies,

what do you do to prevent
these problems?

7. What do you know about

 medical problems in your
family?

8. Has there been any

important illness or injuries
in your life?

A. NUTRITIONAL METABOLIC PATTERN

STATEMENT OF THE PROBLEM PRIOR TO ADMISSION DURING HOSPITALIZATION SIGNIFICANCE PROBLEM IDENTIFIED
1. What is your usual diet
(type)?

2. Are there any cultural /

religious restrictions?

3. Can you recall and state

your meal composition and
feeding pattern?
Carbohydrates/ proteins/
fats/ water/ vitamins and
mineral
Food supplements:

4. How’s your appetite? Are

there any changes you
observed?

5. Do you experience
nausea/ vomiting/
 heartburn/indigestion?
How do you manage it, is it
relieved or not?

6. Can you recall and state

the highest and lowest
weight you have?

7. Last meal / intake

A. PATTERN OF ELIMINATION

STATEMENT OF THE PRIOR TO ADMISSION DURING HOSPITALIZATION SIGNIFICANCE PROBLEM IDENTIFIED

PROBLEM
1. Usual voiding pattern?
Frequency?
Characteristics: color /
odor?

2. Do you experience any

discomforts; pain, burning
and difficulty in voiding?
How do you manage it?

3. Usual bowel pattern?

Frequency?
Characteristics: color/
consistency/ odor?
4. Do you experience any
discomforts; diarrhea,
constipation, bleeding and
hemorrhoids? How do you
manage it? Laxative
used?

5. Do you perspire heavily, in

what occasion/ condition?
6. Do you have any disease
of the digestive system,
urinary system or skin?

A. PATTERN OF ACTIVITY AND EXERCISE

STATEMENT OF THE PRIOR TO ADMISSION DURING HOSPITALIZATION SIGNIFICANCE PROBLEM IDENTIFIED

PROBLEM
1. How do you describe your
weekly pattern of activity
and leisure, exercise and
recreation?

2. Do you have any disease

that affects cardio-
respiratory system or
musculoskeletal system?

3. Do you experience
fatigues / weakness, pain
after the activity?

A. COGNITIVE – PERCEPTUAL PATTERN

STATEMENT OF THE PRIOR TO ADMISSION DURING HOSPITALIZATION SIGNIFICANCE PROBLEM IDENTIFIED

PROBLEM
1. Do you have sensory
deficits (sight, smell,
auditory, taste and
vision)? Are they
corrected?

2. Can this person express

her/ himself clearly and
logically?
3. Does the person have any
disease that affects
mental sensory functions?

4. If this person has pain,

describe it and it’s
causes:

A. PATTERN OF SLEEP AND REST

STATEMENT OF THE PRIOR TO ADMISSION DURING HOSPITALIZATION SIGNIFICANCE PROBLEM IDENTIFIED

PROBLEM
1. Describe your sleeping
pattern? Hours/ naps/
aids/ insomnia related to:

2. Do you feel tired upon

waking up?

3. Do you experience any

problem falling asleep?
What do you think caused
it?

4. Do you feel rested and

relaxed?

A. PATTERN OF SELF PERCEPTION AND SELF – CONCEPT

STATEMENT OF THE PRIOR TO ADMISSION DURING HOSPITALIZATION SIGNIFICANCE PROBLEM IDENTIFIED

PROBLEM
1. Do you think that there is
 anything unusual about
your appearance and self?

2. Are you comfortable with

your appearance?

3. Describe how you feel

right now?

4. What are your traits that

you’re proud of?

5. What are the traits that

you think that needs
changes and
improvements?

6. Are you open for

changes? In what
condition and how?

A. ROLE – RELATIONSHIP PATTERN

STATEMENT OF THE PRIOR TO ADMISSION DURING HOSPITALIZATION SIGNIFICANCE PROBLEM IDENTIFIED

PROBLEM
1. How do you describe
various roles in life
(family, friends,
community) ?
(Has, or does this person
now have positive role
models for these roles?)

2. Which relationships are

most important to you at
present?

3. Are you currently going

through any big changes
in role or relationships?
 What are they?

A. SEXUALITY – REPRODUCTIVE PATTERN

STATEMENT OF THE PROBLEM PRIOR TO ADMISSION DURING HOSPITALIZATION SIGNIFICANCE PROBLEM IDENTIFIED
1. Are you in a relationship?
How many child you wish.
Have? Can you say that
you are sexually active?
Do you use protection?

2. Do you use birth control

method? Do you have
sexual concern/difficulties?
Recent change in
frequency / interest?

3. (Female) age of
menarche, cycle, duration,
no. of pads, LMP,
pregnant now,
menopause, vaginal
mammogram, pap test.
practicing self breast
examination/.

4. (Male) penile discharge,

prostate disorder,
circumcised, vasectomy,
testicle, last proctoscopic/
prostate examination
A. PATTERN OF COPING AND STRESS TOLERANCE

STATEMENT OF THE PRIOR TO ADMISSION DURING HOSPITALIZATION SIGNIFICANCE PROBLEM IDENTIFIED

PROBLEM
1. Have you experienced
any discomforts in life?
What condition brought it?
2. How do you usually cope
with problems?

3. Do these actions help or

make things worse?

4. To whom would you go if

you have problems?

5. Have you undergone

treatment for emotional
distress?

A. PATTERN OF VALUES AND BELIEFS

STATEMENT OF THE PRIOR TO ADMISSION DURING HOSPITALIZATION SIGNIFICANCE PROBLEM IDENTIFIED

PROBLEM
1. What principle in life did
you learn as a child? Do
you think that it is still
important? In what
condition/s?
2. Do you belong in any
cultural, ethnic, religious,
regional, or other groups?
3. Does this give any
influence on your health
behaviors?

4. What support systems do

you have currently?