-Do tou take OTC drugs?

-Do you take drugs or medicines which are not prescribed for Name: Marital Status: you? Age: Occupation: -Are you consulting ³albularyos´? How do you perceive health now that you are sicked? Gender: Religion: 2) Nutritional metabolic pattern Address: Health care resources: Are you taking a balanced diet? What's your typical daily diet? How many cups of rice were you taking during breakfast?lunch?dinner? CHIEF COMPLAINT Do you experienced any difficulty in swallowing? D Are there some health problems bothering you? Among Are there times that you feel lost your appetite in eating? them, which is your main concern right now? When was that? HISTORY OF PRESENT ILLNESS What's your favorite food? D When does the symptom started? Do you have allergic reaction with any food? D How often it occurs? Do you take snacks in between meals? D Does it happengradually or suddenly? How many glass of water are you taking daily? D What are you doing when you feel the unusual things? Are you taking any vitamin? D Kindly specify to me the parts of your body that are being What's your weight? Is there an improvement compared to affected? the previous one? D If you rate the pain you experienced from 1 to 10,what How about your height? Do yohow about its u think it is number would it corresponds? aproppriate with your age? D Are there things that when you do such, the pain was being What's your body temperature daily? aggravated/alleviated? Do you have any skin disease? PAST HISTORY If you are wounded,does your skin easily healed? D What are the illnesses you experienced during your Are there changes in your normal pattern of eating now childhood days? that you got sicked? D Did you undergo any form of vaccinations already? Please 3) Elimination pattern specify. D How many times you urinate aeveryday? D Have you experienced any serious illnesses before? D Can you tell me the amount of your urine in terms of liter? D Do you have any kind of allergies? What do you do when D Do you feel any pain? you experienced having one? D Kindly describe to me the color of your urine? Is it D Prior to this, did you meet any accidents already? Or transparent? injuries? D How about its odor? D When did it happen? D How many times you defacate in a week? D What part of your body was affected? D Is there a pattern in your elimination? D What kind of accident or injury was it? D Kindly describe to me the color of your stool? Is it hard or D What are the treatment you received? soft? GORDON'S FUNCTIONAL HEALTH PATTERN D How about its amount? D Are you using any laxatives or diuretics? 1) Health perception health management model 4) Activity exercise pattern What is a healthy person for you? D What are your daily work? Is health important to you? D Do you think you have enough energy for these daily How do you value your health? activities? How often do you visit your doctor? D What do you usually do during your free time? What are the different ways you perform to maintain D Are you performing exercises or any sort of it? proper hygiene? D How often do you do them? -Do you take a bath everyday? D How do you usually feel after performing such activity? -How many times you brush your teeth? D Is there a change in your respiration? -Do you change your clothes regularly? Do you smoke? D Do you experience any unusual changes? Do you use alcohols? -is there any difficulty in your breathing? What do you usually do when you're sick? -do you experience any muscle ache? BIOGRAPHIC DATA

are there medical D Do you have difficulties in remembering things. 5 pads a since when? D What are the things that give/make you fatigue? D Do you hear things clearly? 11) Value belief system D Can you distinguish one smell from another? D Do you believe that there's god? D Can you decipher the four different D What aws your religion? taste?(sweet.what do you usually do to satisfy your -do you get up at night to go to the bathroom? needs as a male? D What time do you sleep at night? D Do you perform self breast examination? D What time do you wake up in the morning? D Do oyu perform testicular self examination D How many minutes do you take a nap during daytime? 10) Coping stress tolerance D Are you taking sleeping tablets? D What do you do when you feel stressed? 6) Cognitive-perceptual pattern -do you eat too much.are you having an eye to eye contact with him/her? D Kindly tell me what are your talents/weaknesses? D What are youf fears in life? D Which do you prefer most of the time. are you having a dysmenorrhea? What D Do you sleep continously? Or are there interruptions in do you usually do to relieve the pain? between? D If you are single.sister. cry.sour) D Do you communicate with him? Through what? D What is your favorite subject before when you were in grade school? D Are there any superstitious beliefs you usually do related to health? D What did you do before going to this appointment? In your religion.bitter.g.e.how often do you have sexual D Kindly tell me the changes happened in your usual intercourse? activities now that you are sick compared before? D Are you satisfied after the intercourse? 5) Sleep rest pattern D Do you have a regular menstrual period? D Do you think you have a healthy sleep pattern? D How many pads do you consume in a day? D How many hours do you sleep? D During those times.take a nap.parents) D Do you feel comfortable at your house? D Do you greet or give gifts to your loved ones when the celebrate special ocassions? D How do you fulfill your responsibilities at your house? 9) Sexuality reproductive pattern .-doyou feel dizzy? D Do you have any problem with your reproductive system? D do you get easily tired? D Are you married? If yes. where D practices which are not allowed? do you put that thing? 7) Self perception self concept pattern How do you feel about yourself? D Are you contented on being you? How? D Kindly tell me what are your greatest achievements as of now? D Do you believe in your self? How high is your self esteem? D Are you looking to yourself as superior to others? D When you talk to somebody. to be alone or to be with many people?Why? 8) Role relationship pattern D How is your relationship with your family?(to your brother. hit yourself or what? D Are you having a monthly check up with your different D Are you fond of attending 'gimiks' or any recreational senses? activities? D Can you see things clearly? D Does it help you feel relieved? D Are you nearsighted/farsighted? D Do you usually ask help from others ?about 5 pads a about D How long are you using your eyeglasses/contact lenses.salty.