PATIENT’S PROFILE

First Name Last Name MI

Picture
Age Gender Nationality

Address

Place of Birth Civil Status

Date of Birth Number of Children

Language Occupation

Contact Number SO

Religion Educational Attainment

Provider of History Language

Height Weight BMI Chief Complaint

Vital Signs: Admitting Diagnosis

Blood Pressure Final Diagnosis

Respiratory Rate Attending Physician

Pulse Rate Date of Admission

Temperature Admitting Institution

Date Handled Time Handled

Notes/Comments:

SAVE
FAMILY HISTORY MEDICAL HISTORY

Has anyone in the family (parents, grand- Have you ever had:
parents, aunts/uncles, sisters/brothers) had:
Ye No Who? Yes No
s Allergies (List) ☐ ☐
Allergies (List) ☐ ☐ ________________________
_______________ Asthma ☐ ☐
Asthma ☐ ☐ Chicken Pox (Year) _______ ☐ ☐
TB/Lung Disease ☐ ☐ Frequent Ear Infections ☐ ☐
HIV/AIDS ☐ ☐ Vision Problems ☐ ☐
Suicide Attempts ☐ ☐ Hearing Problems ☐ ☐
Heart Disease ☐ ☐ Skin Problems ☐ ☐
Stroke ☐ ☐ TB/Lung Disease ☐ ☐
High Blood Pressure ☐ ☐ Seizures ☐ ☐
High Cholesterol ☐ ☐ High Blood Pressure ☐ ☐
Blood Disorders ☐ ☐ Heart Disease ☐ ☐
Diabetes ☐ ☐ Hepatitis ☐ ☐
Seizures ☐ ☐ Diabetes ☐ ☐
Mental Illness ☐ ☐ Kidney Disease ☐ ☐
Cancer ☐ ☐ Physical/Learning Disabilities ☐ ☐
Birth Defects ☐ ☐ Bleeding Disorders ☐ ☐
Hearing Loss ☐ ☐ Sexually Transmitted Diseases ☐ ☐
Speech Problems ☐ ☐ Emotional or Behavioral ☐ ☐
Kidney Disease ☐ ☐ Problems
Alcohol/Drug Abuse ☐ ☐ Depression/Suicidal Thoughts ☐ ☐
Hepatitis ☐ ☐ Hospitalizations/Surgeries ☐ ☐
Thyroid Disease ☐ ☐ Physical Abuse ☐ ☐
Attention Deficit ☐ ☐ Emotional Abuse ☐ ☐
Disorder Sexual Abuse ☐ ☐
Family Violence ☐ ☐ Bone or Joint Injuries ☐ ☐
Obesity ☐ ☐
Other: ______________________________ Eating Disorders ☐ ☐
Other:
______________________________
Current Medications: __________________

SAVE
 GORDON’S 11 FUNCTIONAL PATTERN

I. Health Perception – Health Management

How would you rate your health on a scale of 1 to 10 now?
Describe your illness or current health problems.

What do you usually do when you have health problems?

Do you take/use alcohol, caffeine, cigarettes?

Have you been able to take your prescribed medications?

Do you have allergies? If yes, what do you usually do to prevent problems?

Have there been any important illnesses or injuries?

Do you have any difficulties in caring for yourself or others at home?

Do your current daily activities affect your health?

 II. NUTRITIONAL – METABOLIC PATTERN

Describe the type and amount of food you eat at breakfast, lunch and supper everyday.

Do you take any vitamin supplements or herbal supplements?

Do you ever experience nausea/vomiting? Abdominal pain? Sore throat/tongue?

What would you consider to be your ideal weight? Have you had any recent weight gain or
losses?

Do you notice any changes in your eating habits?

III. ELIMINATION

Describe your bowel pattern. Have there been any recent changes?

How frequent are your bowel movements? What is the color and consistency of your stools?

Do you have any discomfort with your bowel movements?

 How frequently do you urinate?

What is the amount and color of your urine?

Do you have any problems when urinating? Such as pain, blood in urine, etc.

IV. ACTIVITY – EXERCISE

What are your activities in daily living? Describe your activities on a normal day.

Do you have difficulty with any of these activities?

What leisure activities you usually enjoy?

What are the activities that you considered as your exercise?

What do you do for a living?

V. COGNITIVE – PERCEPTUAL PATTERN

What is the best way for you to learn something new?

How do you feel about your current state of health?

Do you have any difficulty expressing yourself or explaining things to others?

Are you able to remember recent events or events of long ago?

What assists you in making decisions? How do you face your problems?

Do you find decision making difficult?

VI. SLEEP – REST PATTERN

Describe your usual sleeping time and habits.

How long does it take you to fall asleep? If you woke up during sleeping hours, how long does it
take you to fall asleep again?
 Do you use anything to help you fall asleep?

Do you ever experience difficulty with falling asleep?

Do you feel fatigued after a sleep period?

Has your current health altered your normal sleeping habits?

VII. SELF PERCEPTION – SELF CONCEPT

How do you describe yourself?

What do you consider to be your strengths and weaknesses?

How do you feel about yourself? Your appearance?

How do you feel about other people with disabilities?

VIII. ROLE – RELATIONSHIP

Describe your family.

How do you feel about your family?

What is your role in your family?

Does your family experience problems? If yes, how does your family deal with it?

Describe your occupation. What is your major responsibility at work?

How do you feel about the people you work with?

How do you feel about the people in your community?

Describe your neighborhood and the community in which you live.

IX. SEXUALITY – REPRODUCTIVE PATTERN

How old are you when you begin menstruating? How old are you when you were circumcised?

Have you notice any changes in your menstrual cycle?

Do you experience episodes of flushing, chillings, or intolerance to temperature changes?

Describe any mood changes or discomfort during or after your period.

How many times have you been pregnant? How old are they and what are their gender?

Have you had any difficulty with fertility? If yes, does it affect your relationship with your
partner?

Describe your sexual feelings & your level of satisfaction from your sexual relationship on a
scale of 1 to 10.

Do you feel any pain or discomfort during sexual intercourse?

X. COPING – STRESS TOLERANCE

Has there been a personal loss or major change in your life over the last years? If yes, what has
helped you to cope with this change or loss?

What do you usually do 1st when facing a problem?

What helps you relieve stress and tension?

Do you use medication, drugs, or alcohol to help relieve stress?

Do you have any treatment for emotional distress?

XI. VALUE – BELIEF

What is most important in your life?

What do you hope to accomplish in your life?

What is your major source of hope and strength in life?

Do you have a religious affiliation?

Are there certain health practices or restrictions that are important for you to follow?

Is a relationship with God an important part of your life?

SAVE
PATIENT’S SIGNS & SYMPTOMS 5.
1. Nausea  Vertigo
Vomiting  Appendicitis These are the
recommended
Loss of appetite  Food poisoning diseases or
 Flu complications based
on the symptoms
 Diarrhea that were provided.
 Constipation
 Dehydration

2. Nausea  Vertigo
Vomiting  Flu
Loss of appetite  Diarrhea
Headache  Constipation
 Dehydration

3. Nausea
 Vertigo
Vomiting
 Flu
Loss of appetite
 Diarrhea
Headache
 Dehydration
Dizziness

4. Nausea
Vomiting
 Vertigo
Loss of appetite
 Flu
Headache
 Dehydration
Dizziness
Fainting
 Nausea
Vomiting
Loss of appetite
Headache
Dizziness  Vertigo
Fainting
Loss of balance
Ringing in the ears
Hearing loss