UNIVERSITY OF SAN JOSE – RECOLETOS

School of Allied Medical Sciences

Nursing

GORDON’S FUNCTIONAL HEALTH PATTERNS

Patient’s Name : _____________________________ Date of Birth : ________________________________

Gender : ______________________________ Diagnosis/Problem List: ___________________________
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Age : _____________________________ Hospital : ________________________________
Address : _____________________________ Doctor/s : ________________________________
Status : _____________________________ Religion : ________________________________

CHIEF COMPLAINT/S:

HISTORY OF PAST ILLNESS:

HISTORY OF PRESENT ILLNESS:

1. Health Perception/ Health Problem

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2. Nutritional Metabolic Pattern

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3. Elimination Pattern
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4. Activity Exercise Pattern

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 5. Sleep – Rest Pattern
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6. Cognitive Perceptual Pattern

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7. Self-Perception Pattern
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8. Role – Relationship
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9. Sexuality – Reproductive Pattern

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10. Coping Areas Management Pattern

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11. Value Belief System

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Genogram: