Professional Documents
Culture Documents
A. Initial Database
Name: __________________
Age: __________Sex:______________
Occupation: ___________________
Age:_____Address:____________________
Father’s Name:___________________________
Occupation:___________________________
Age:________Address:_________________
Tel. No:______________________________
Religion:________________
Primary Language:______________
Nationality:__________________
B. General Assessment
2. Parent-child interaction
4. Home environment
asydbsabcbsalncu
GORDON’S FUNCTIONAL HEALTH PATTERN FOR PEDIATRIC CLIENTS
D. Vital Signs
Wt__________
Ht:__________
BP__________
3. Perinatal History
a. Wt and Ht at birth
________ __________
asydbsabcbsalncu
GORDON’S FUNCTIONAL HEALTH PATTERN FOR PEDIATRIC CLIENTS
c. Dentition (including age of onset, number of teeth and symptoms during teething)
_____________________________________________________________________________
___________________
asydbsabcbsalncu
GORDON’S FUNCTIONAL HEALTH PATTERN FOR PEDIATRIC CLIENTS
3. Elimination Pattern
● What are your child’s toilet habits? (diaper, toilet trained [day only or day and night], use of words to
communicate urination and defecation, potty chair, regular toilet, other routines)?
● What is his usual pattern of elimination (bowel movements)
● Do you have any concerns about elimination (bed wetting, constipation, diarrhea)
● What do you do for these problems?
● Have you ever noticed that your child sweats a lot?
4. Sleep-Rest Pattern
● What is your child’s usual hour of sleep and awakening?
● What is his schedule for naps/length of naps?
● Is there a special routine before sleeping (bottle, drink of water, bedtime story, nightlight, favorite
blanket, or toy or prayers)
● Is there a special routine during sleep time such as walking to go to the bathroom?
● What type of bed does he sleep on?
● Does he have his own room or share a room: if he shares a room, with whom?
● What are the home sleeping arrangements (along or with others, such as sibling parent or other
person)?
● What is his favorite sleeping position?
● Are there any problems awakening and getting ready in the morning?
● What do you do for these problems?
5. Activity-Exercise Pattern
● What is your child’s schedule during the day? (nursery school, daycare center, regular school,
extracurricular activities)
● What are his favorite activities or toys (both active and quiet interests)
● What is his usual television-viewing schedule at home?
● What are his favorite programs?
● Are there any television restrictions?
● Does your child have any illness or disabilities that limit his activity? If so, how?
● What are his usual habits and schedule for bathing? (bath in the tub or shower, sponge bath, shampoo?
● What are his dental habits (brushing, flossing, fluoride supplements or rinses, favorite toothpaste,
schedule of daily dental care)
● Does your child need help with dressing or grooming such as hair combing?
● Are there any problems with the above (dislike or refusal to bathe, shampoo hair or brush teeth)
● What do you do with these problems?
● Are there special devices that your child requires help in managing (eyeglasses, contact lenses, hearing
aid, orthodontic appliance, artificial elimination appliances, orthopedic devices)
● Note: Use the following code to assess functional self care level for feeding, bathing/hygiene,
dressing/grooming, toileting:
� 0 – full self care
� 1 – requires use if equipment or device
� 2 – requires assistance or supervision from another person and equipment or device
� Is dependent and does not participate
6. Cognitive-Perceptual Pattern
● Does your child have any hearing difficulty?
� Does he use hearing aid?
� Have tubes been placed in your child’s ears?
● Does your child have any vision problems?
� Doe she wear eyeglasses or lenses?
● Does your child have any learning difficulties?
� What is his grade in school?
asydbsabcbsalncu
GORDON’S FUNCTIONAL HEALTH PATTERN FOR PEDIATRIC CLIENTS
● What have been your child’s experiences with and reactions to temporary separation from you (parent)?
● Does your child have any fears (places, objects, animals, people, situations)? How do you handle
them?
● Do you think your child’s illness has changed the way he thinks about himself (more shy, embarrassed
about appearance, less competitive with friends, stays home more)?
9. Sexuality-Reproductive Pattern
(Answer questions that apply to child’s age-group)
● Has your child begun puberty (developing physical, sexual characteristics, menstruation)? Have you or
your child had any concerns?
● Does your daughter know how to do BSE?
● Does your child know how to do TSE?
● Have you approached topics of sexuality with your child? Do you feel you might need some help with
some topics?
● Has your child’s illness affected the way he or she feels about being a male or female? If so, how?
● Do you have any concerns with behaviors in your child such as masturbation, asking many questions or
talking about sex, nit respecting others privacy, or wanting too much privacy)?
● Initiate a conversation about adolescent’s sexual concerns with open-ended to more direct questions
and using the terms “friends” or “partners” rather than girlfriend or boyfriend
A. Tell me about your social life
B. Who are your closest friends? (if one friend is identified, could ask more about that relationship,
such as how much time they spend together, how serious they are about each other, if the
relationship is going that way the teenager hoped it would)
C. Might ask about dating and sexual issues, such as the teenager’s views on sex education,
“going steady”, living together or premarital sex
D. Which friends would you like to have visit in the hospital?
asydbsabcbsalncu
GORDON’S FUNCTIONAL HEALTH PATTERN FOR PEDIATRIC CLIENTS
Language Skills
Personal-Social
Total Score:____________________________
6
asydbsabcbsalncu
GORDON’S FUNCTIONAL HEALTH PATTERN FOR PEDIATRIC CLIENTS
13. Which line is longer? (Not bigger). Turn paper upside down and repeat (pass 3 of 3 or 5 of 6).
When giving items 12, 4 and 15, do not name the forms. Do not demonstrate 12 and 14.
16. When scoring, each pair (2 arms, 2 legs, etc.) Count as one part.
17. Place one cube in cup and shake gently near child’s ear, but out of sight. Repeat for other ear.
18. Point to picture and have child name it. (No credit is given for sounds only). If less than 4 pictures are named
correctly, have child point picture as each is named by tester.
asydbsabcbsalncu
GORDON’S FUNCTIONAL HEALTH PATTERN FOR PEDIATRIC CLIENTS
19. Using doll, tell child: show me the nose, eyes, ears, mouth, hands, feet, tummy, hair. Pass 6 out of 8.
20. Using pictures, ask child; which one flies? Says meow? Talks? Used to play? Used as a clothing? Pass 2 of
3 or 4 out of 5.
21. Ask child: What do you do when you are cold? Tired? Hungry? Pass 2 of 3, 3 of 3.
22. Ask child; what do you do with a cup? What is a chair used for? What is a pencil used for? Action words
must be included in the answer.
23. Pass if child correctly places and says how many blocks are there on paper (1,5).
24. Tell child; Put block on the table; under table; in front of me, behind me. Pass 4 of 4. (Do not help child by
pointing, moving head or eyes).
25. Ask child what is a ball? Lake? Desk? House? Banana? Curtain? Fence? Ceiling? Pass if defined in terms
of use, shape, what is it made from or general category (such as banana as fruit, not just yellow). Pass 5 of
8, 7 of 8.
26. Ask child: if a horse is big, a mouse is ________? If fire is hot, ice is _______?If the sun shines during the
day, the moon shines during________?Pass 2 out of 3.
27. Child may use wall or rail only, not person. May not crawl.
28. Child must throw ball overhand 3 feet to within arm’s reach of tester.
29. Child must perform standing broad jump over width of test sheet (8 1/2 inches).
30. Tell child to walk forward, Heel within 1 inch of toe. Tester may demonstrate. Child must walk 4 consecutive
steps.
31. In the second year, half of children are non-compliant.
Observations:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Denver II Scoring
Interpretation of Denver II scores
Advanced – Passed an item completely to the right of the age line (passed by less than 25% of children at an
age older than the child).
OK- Passed, failed, or refused an item intersected by the age line between the 25 th and 75th percentiles.
Caution- Failed, or refused item s intersected by the age line on or between the 75 th and 90th percentiles.
Delay – Failed an item completely to the left of the age line; refusals to the left of the age line may also be
considered delays, since the reason for the refusal may be inability to perform the task.
Interpretation of Test
asydbsabcbsalncu