Biographic Data:

Name:
Age:
Gender:
Birth date:
Birth place:
Ethnicity:
Marital Status:
Address:
Religion:
Occupation:
Mother’s Name:
Father’s Name:
Education Level:
Current height:
Current weight:

Past Health History:

Problems at birth:
Childhood illnesses:
Last immunization date:
Any surgeries:
Any allergies:
Any accidents:
Any pain pattern:

Present Health Concern:

Character of pain:
Onset:
Location:
Duration:
Severity:
Pattern:
Associated factors:

Lifestyle Health Practices:

Description of a typical day:

24-hour dietary intake:
Activities on a typical day:
Exercise habit/s:
Sleep habit/s:
Drugs intake:
Stressors in life:

Developmental Level:

o 5 – 12 years: Industry vs. Inferiority

o 13 – 19 years: Identity vs. Role confusion
o 20 – 40 years: Intimacy vs. Isolation
o 40 – 65 years: Generativity vs. Stagnation
o 65 and older: Ego integrity vs. Despair
 Gordon’s 11 Functional Health Patterns

A. Health Perception Management

Risk for frail elderly Do you feel that your knee Nadarama mo na ba ng
syndrome muscles are weakening? paghina ng iyong kalamnan
sa tuhod?
Ineffective Health Do you have a family history Mayroon ka bang kasaysayan
Management of hypertension? ng sakit sa puso sa iyong
pamilya?
Ineffective Protection Do you practice safe sex? Ginagawa mo ba ang ligtas na
sex?
Risk for Bleeding Do you often see blood in Madalas ka bang nakakakita
your stool? ng dugo sa iyong tae?
Risk for Infection What caused your open Ano ang naging dahilan ng
wound? iyong sugat?
Risk for Injury Do you have a safe Mayroon ka bang ligtas na
environment at home? kapaligiran sa bahay?
Risk for Poisoning When you eat, do you make Kapag kumain ka, tinitiyak
sure to check if the food if it mo bang suriin kung ang
is spoiled or not? pagkain ay sira na o hindi?
Risk for Suffocation Do you feed your 4 month Pinapakain mo ba ng matigas
old child solid food? na pagkain ang iyong apat na
buwang anak?
Risk for Trauma Did you have any accident for Nagkaroon ka ba ng
the past month? aksidente sa nakalipas na
buwan?
Risk – prone Health Behavior Do you smoke? If yes, how Naninigarilyo ka ba? Kung
many times in a day do you oo, gaano karaming beses sa
do it? isang araw mo ito ginagawa?

Do you consume alcohol Umiinom ka ba ng alak?

beverages? If yes, how often? Kung oo, gaano kadalas?

How's your health been lately?

How do you take care of yourself?
Can you tell me what activities do you believe keep you healthy?
Do you have any allergies?
Have you had any surgery in the past?
Any colds in the past week or months?
Have you used any medicine recently?
Do you have a history of chronic illness? If so, what and when did it start?
What do you do when you have a health problem?
When was the last time you visited your physician? For what reason?
How often do you visit for check-ups and physical examinations?
On a scale of 1 to 10, 10 being the best/highest, how satisfied are you with your current overall
health?

B. Nutritional / Metabolic

Insufficient breast milk Is there an absence of milk Mayroon bang pagkawala ng

production with nipple
stimulation from the mother?
Ineffective breastfeeding Does the infant have a poor
sucking reflex?
Interrupted breastfeeding Is the infant premature?
Readiness for enhanced Does the mother express
breastfeeding desire to enhance the ability
to provide breastmilk?
Ineffective infant feeding Does the infant have a hard
pattern time to suck, swallow and
breathe?
Imbalanced nutrition: less Do you lack sufficient
than body requirements interest in food?
Obesity Do you have any disordered
eating behaviors?
Overweight Do you love to eat sweets?
Risk for overweight Do you have a genetic
disorder of rapidly gaining
weight?
Impaired swallowing Do you feel irritable when
you swallow?
produksyon ng gatas na may
utong pagpapasigla mula sa
ina?
Mahina baa ng pagsipsip ng
sanggol sa kanyang ina?
Ang sanggol ba ay
naipanganak sa hindi pa niya
kabuwanan?
Nagpapahayag ba ang ina ng
pagnanais na mapahusay ang
kakayahang magbigay ng
breastmilk?
Nahihirapan ba ang sanggol
na sumipsip, lumunok ay
huminga?
Wala ka bang sapat na interes
sa pagkain?
Mayroon ka bang anumang
mga disorder na pag-uugali sa
pagkain?
Mahilig ka bang kumain ng
matatamis na pagkain?
Mayroon ka bang genetic
disorder ng mabilis na
pagtaas ng timbang?
Naiirita ka ba kapag ikaw ay
lumulunok?

What time do you usually eat your meals?

Are you fond of fasting? How often do you eat?
What kind of food do you usually prefer?
Are you allergic to any food, drinks, or medicines?
Do you experience any discomfort whenever you are eating?
Do you experience any skin problems?
How long does it usually take for your wounds to heal?
Do you experience problems with your teeth? Hair? Nails?
Do you engage or follow a certain diet program? If yes, what kind of diet?
Did you recently gain/lose weight?
Did you recently increase/decrease your height?
Do you take any vitamins? Supplements?
How many glasses do you drink in a day?
Do you drink alcohol? How often?

C. Sleep and Rest

Insomnia Are you feeling depressed? Nalulungkot ka ba?

Sleep deprivation Can you sleep when your
environment is noisy?
Readiness for enhanced sleep Do you sleep on time?
Disturbed sleep pattern Are you having a difficulty in
initiating sleep?
Impaired sitting Can you easily flex or move
your both knees?
Impaired standing Can you stand still?
Fatigue Do you easily get tired after
any physical activity?
Wandering Do you sometimes feel that
you are gradually moving
from place to place?
Decreased cardiac output Could you observe any
abnormalities in your skin
color?
Activity intolerance Do you sometimes feel that
you have an abnormal heart
rate response due some
cardiovascular activities?
Kaya mo bang matulog kahit
maingay ang iyong
kapaligiran?
Natutulog ka ba sa tamang
oras?
Nahihirapan ka bang simulan
ang iyong pagtulog?
Kaya mo bang madaling
ibaluktot o ilipat ang iyong
dalawang tuhod?
Kaya mo bang tumayo ng
tuwid?
Madali ka bang mapagod
matapos ang anumang pisikal
na aktibidad?
Paminsan-minsan ba ay
nadarama mon a ikaw ay
unti-unting lumilipat mula sa
isang lugar patungo sa isa
pang lugar?
Maaari mo bang obserbahan
ang anumang mga
abnormalidad sa kulay ng
iyong balat?
Sa palagay mo ba ay mayroon
kang abnormal na tugon ng
puso sahil sa mga aktibidad
sa cardiovascular?

How many hours did you spend relaxing daily?

What things make you relaxed?
What things make you unrelaxed?
What time do you usually sleep?
Are there any changes in your sleeping pattern lately?
Approximately, how long does it take you before you fall asleep?
Given your current situation, do you use anything to help you sleep? Medication (sleeping pills)?
Any home remedies? Sleeping habits or routine?
Do you experience sleep interruption? If yes, how often?
Do you experience nightmares? If yes, how often?
Do you ever feel fatigued after a sleep period?
What do you feel when you have low-quality and incomplete hours of sleep?
Do you experience unusual sleep behaviors? (snoring, sleepwalking, talking, etc.)

D. Cognition and Perception

Unilateral neglect Do you often use the vertical
half of the page only when
you’re writing?
Acute confusion Do you sometimes feel that
you are hallucinating?
Risk for acute Do you have a family history
confusion of cerebral vascular accident?
Chronic confusion Could you have an alteration
in your personality?
Labile emotional control Do you feel that you are
useless because of your
illness?
Ineffective impulse control Could you still control your
anger once it is triggered?
Deficient knowledge Are you having a hard time in
concentrating?
Impaired memory Do you often forget things?
Readiness for enhanced Could you express what you
communication feel in your body?
Impaired verbal Do you have a difficulty in
communication hearing which makes it
difficult for you to understand
the one who’s talking?
Madalas mong gagamitin ang
vertical na kalahati ng pahina
kapag nagsusulat ka?
Nadarama mo ba kung
minsan na ikaw ay nahihilo?
Mayroon ka bang kasaysayan
ng pamilya ng aksidente sa
tserebral na vascular?
Maaari mo bang maiba iba
ang iyong personalidad?
Nararamdaman mo bang wala
kang silbi dahil sa iyong
sakit?
Maaari mo pa bang kontrolin
ang iyong galit kapag na-
trigger na ito?
Nahihirapan ka bang
magkaroon ng pokus?
Madalas ka bang makalimot
ng mga bagay-bagay?
Maaari mo bang ipahayag
ang iyong nararamdaman sa
iyong katawan?
Mayroon ka bang kahirapan
sa pandinig na nagpapahirap
sa iyo na maunawaan ang
nagsasalita?

Do you know what day is it today?

Do you experience difficulty in concentrating in one task?
Do you get distracted most of the time?
When you realize that you do get distracted, what do you do to get back to your senses?
Is there any part of your senses that you feel you are lacking?
Have you encountered any problem learning new tasks or skills? (e.g. learning a foreign language,
trying out a new hobby/sport, etc.)
Have you struggled to begin and maintain a conversation?
Was there a time you had difficulty remembering to do important things?
Is there anything you are sensitive to? (e.g sound and sight)
Can you recall the activities you did before the time you experienced pain?
Any medications you take to help you with your current health problem?

E. Sexuality / Reproductive

Did you had any relationships? Nagkaroon ka na ba ng mga karelasyon?

For female: when did you have your first
period?
Does your menstrual period come regularly?
Do you have any menstrual problem?
Do you use contraceptives when you have
sex?
For male: In what age were you circumcised?
How many times a week do you masturbate?
Are you sexually active?
Do you use condoms when you have sex?
Do you feel satisfied when you have sex?
Kailan ka unang dinatnan ng iyong regla?
Regular ba ang dating ng iyong regla?
Mayroon ka bang problema sa iyong regla?
Gumagamit ka ba ng pangontra sa
pagbubuntis kapag ikaw ay nakikipagtalik?
Ilang taon ka noong ikaw ay tinuli?
Ilang beses ka sa isang linggo nagsasalsal?
Aktibo ka ba sa pagkikipagtalik?
Gumagamit ka ba ng proteksyon kapag ikaw
ay nakikipagtalik?
Nasisiyahan ka ba kapag ikaw ay
nakikipagtalik?

Are you well educated on sex education? Or do you have any basic knowledge about sex
education?
Have you ever experienced sexual intercourse? If yes, how frequent do you have sex?
Do you practice safe sex? If yes, what contraceptive methods do you apply?
What do you do after sex?
Do you clean yourself up after sex?
Have you committed any sexual acts, such as masturbation?
Any discharge or any unusual odor or color from your genital area?
Is your sexual relationships satisfying? Are there problems? Changes?

F. Coping / Stress Tolerance

Did you happen to have a crisis in your life?
How did you cope up with that event in your
life?
Who helped you to move on and forget the
things that happened in that situation?
Who is the person that is always available to
talk to you?
When do you get tensed? What do you do?
Do you happen to just drink alcohol for you
to be relaxed?
Nagkaroon ka na ba ng krisis sa iyong buhay?
Paano mo nakayanan ang mga naging
kaganapan sa iyong buhay?
Sino ang tumulong sa iyo upang magpahinog
at kalimutan ang mga bagay na nangyari sa
sitwasyon iyon?
Sino ang taong laging nandiyan upang
makipag-usap sayo?
Kapag ikaw ay natataranta, ano nag iyong
ginagawa?
Minsan ba umiinom ka nalang ng alak upang
mas mapanatag ang iyong loob?
 Do you use medications to lessen your stress?
When you have a problem, how do you
handle it?
Are these problems stressful?
Does these problems create a big impact in
your life?
Gumagamit/umiinom ka ba ng gamot upang
mabawasan ang iyong stress?
Kapag ikaw ay may problema, paano mo ito
inaayos?
Nakakabahala ba ang mga problemang ito?
Ang mga problema bang ito ay gumagawa ng
malaking epekto sa iyong buhay?

Do you talk about your problems?

Have you experienced stress lately? If yes, on what factors?
What triggers your stress?
Does stress affect your behaviour?
How do you handle/relieve stressors that you encounter?
What do you do when you feel stressed or burnout?
Have experienced any suicidal tendencies?
Have committed anything that results to self-harm?
Do you have a support group/peers?

G. Self-Perception / Self-Concept

How would you describe yourself?
Do you feel contented with yourself?
Do you feel any changes in your body?
What are the things that make you feel angry?
Do you frequently feel depressed?
Are you able to control your feelings?
Did you ever feel that you lose hope?
What are the things that help you lessen your
problems?
Have you ever consulted a doctor?
Why are you nervous when you talk to other
people?
Paano mo mailalarawan ang iyong sarili?
Masaya ka ba sa iyong sarili?
Nakakaramdam ka ba ng pagbabago sa iyong
katawan?
Ano ang mga bagay na nagpapagalit sa iyo?
Madalas ka bang nakakaramdam ng
kalungkutan?
Kaya mo bang pigilan ang iyong damdamin?
Naramdaman mo na bang mawalan ng pag-
asa?
Ano ang mga bagay na nakakatulong sa
pagbawas ng iyong problema?
Kumunsulta ka na ba sa doctor?
Bakit ka kinakabahan sa tuwing kakausap ka
ng ibang tao?

Describe how you feel right now.

How do you feel about your appearance?
Do you feel confident about yourself?
Do you get conscious with your body size? Conscious how others perceive you and your body?
If you could, how would you change your body or yourself entirely?
What do you do when you become anxious or worry too much?
Is giving yourself a break can improve your self-perception? Why?
Do you believe that building positive relationships can either improve self-perception?
 H. Roles / Relationships

Do you live alone? Ikaw lang ba mag-isa ang nakatira sa iyong

Do you depend on your family?
Are you having some problems at home?
Does your family take care of you when
you’re sick?
Dis you encounter any problem when you
were a child?
Do you have friends at your neighborhood?
Do you open up to your friends?
What do you feel in your work environment?
Is your income sufficient for your needs?
Do you feel alone in your neighborhood?
bahay?
Nakadepende ka ba sa iyong pamilya?
Nagkakaroon ka ba ng problema sa inyong
bahay?
Inaalagaan ka ba ng iyong pamilya kapag
ikaw ay may sakit?
Nagkaroon ka ba ng problema noong ikaw ay
bata pa?
May mga kaibigan ka ba sa inyong
komunidad?
Nagsasabi ka ba ng iyong mga dinadamsam
sa iyong mga kaibigan?
Ano ang iyong nararamdaman sa lugar kung
saan ka nagtratrabaho?
Sapat ba ang iyong kinikitang sahod para sa
iyong gastusin?
Pakiramdam mo ba na nag-iisa ka sa iyong
komunidad?

How would you describe your relationship with your family?

Do you experience any conflict in your family?
Do you feel safe or somewhat relieved to tell them what you feel?
What is your current marital status? If in a relationship/married, are you experiencing any conflict?
On what factors it contributes?
Do you have friends?
Do you share what you feel to them?
How do you manage to open up to others?
Are you a part or a member of any active groups such as the neighborhood community?

I. Elimination

Impared urinary elimination
Readiness for enhanced
urinary elimination
Functional urinary
incontinence
Reflex urinary incontinence
Are you unable to empty your Hindi mo ba nailalabas lahat
bladder completely when you ng tubig sa iyong pantog
urinate? kapag ikaw ay umiihi?
Do you often feel like you Madalas mo bang
need to urinate? maramdaman na kailangan
mo nang umihi?
Are you able to completely Nailalabas mo ba ang lahat ng
empty your bladder when you tubig sa iyong pantog kapag
urinate? ikaw ay umiihi?
Are you having a hard time to Nahihirapan ka bang umihi?
urinate?
 Stress urinary incontinence
Urge urinary incontinence
Risk for functional chronic
functional constipation
Perceived constipation
Bowel incontinence
Dysfunctional gastrointestinal
motility
Can you control your bladder
upon urinating?
Upon urgency to void, can
you reach the toilet in time?
Do you intake a low fiber diet
Do you use laxatives when
you are constipated?
Do you have any chronic
diarrhea?
Are you having a difficulty
with defecation?
Kaya mo bang kontrolin ang
iyong pantog sa pag-ihi?
Kapag ihing-ihi ka na, kaya
mo pa bang tiisin hanggang
sa makapunta ka sa inidoro?
Gumagamit ka ba ng
mababang diyeta sa hibla?
Gumagamit k aba ng
laxatives kapag nahihirapan
kang tumae?
Mayroon ka bang anumang
talamak na pagtatae?
Nahihirapan ka bang ilabas
ang iyong tae?

Do you have problems with your bowel movement?

Any difficulties defecating?
How is the consistency of the stool? Is it hard? Firm and soft? Or watery-like?
How is the color of the stool? Yellow? Brown? Green? Black or tarry?
What is the shape/size of the stool? *use bristol stool scale*
Do you use laxative? If yes, what type?
Do you have difficulties when urinating?
How frequent do you urinate?
Do you experience any urinary retention, dribbling or dysuria?
Color of urine? Amount of urine?
Is there a presence of blood when urinating?
Do you notice any unusual odor? Any discharge when urinating?
Do you refrain yourself from urinating and/or defecating even when you feel the need to do so?

J. Activity / Exercise

Do you feel energized when you wake up?
What is your daily activity?
Do you spend time in exercising?
Do you go to the gym regularly?
What type of exercises do you do?
Do you have time for relaxation?
Do you play sports?
Could you still play and run with kids?
Could you go shopping alone?
Pakiramdam mo ba ay may sapat kang
enerhiya sa iyong pagkagising?
Ano ang iyong pang araw-araw na aktibidad?
Naglalaan ka ba ng oras sa page-ehersisyo?
Madalas ka bang pumunta sa gym?
Anong uri ng mga ehersisyo ang iyong
ginagawa?
Mayroon ka bang oras para sa pagpapahinga?
Naglalaro ka ba ng sports?
Kaya mo pa bang makipaglaro at
makipaghabulan sa mga bata?
Nakakapagpamili ka ba mag-isa?
 Could you cook and feed yourself? Kaya mo bang magluto at pakainin ang iyong
sarili?

How would you describe your lifestyle?

Do you exercise? If yes, how often?
Do you follow a certain workout routine? If yes, what kind?
Have you encountered any difficulties during exercise or leisure activities?
What do you do during free time? What are your hobbies?
Are you working? If yes, what kind of work do you have?
Has your current health affect your ability to enjoy your hobbies or any leisure activities?

K. Values / Belief Pattern

What are the things you want in life?
Does being religious help you get these
things?
Do you already have plans for your future?
Does religion affect your personality?
Does your belief focuses in what you
practice?
Does your faith help you in time of need?
Does your personality depend on your belief?
Do you value your health?
Is there food that you are not allowed to eat?
If there is an emergency and you need
to eat the food that you’re not allowed
to eat, would you eat it?
Ano ang mga bagay na gusto mo sa iyong
buhay?
Nakakatulong ba ang pagiging relihiyoso
upang makamit amg mga bagay na ito?
May plano ka na ba para sa iyong
kinabukasan?
Nakakaapekto ba ang relihiyon sa iyong
pagkatao?
Ang iyong paniniwala ba ay nakatutok sa
kung anong iyong ginagawa?
Natutulungan ka ba ng iyong paniniwala sa
diyos sa araw na ikaw ay nangangailangan?
Nakadepende baa ng iyong paniniwala sa
iyong pagkatao?
Pinapahalagahan mo ba ang iyong kalusugan?
May mga pagkain ka bang bawal kainin?
Kung may emergency at kailangan mong
kainin ang pagkaing bawal mong kainin dahil
sa iyong relihiyon, kakainin mo ba ito?

Are your satisfied with your progress in life?

Do you generally get things you want out of your life?
Tell us something you would consider as important.
What are your goals in life or what are your plans for the future?
What are the values or principle that you hold onto?
Do you have a religion? If yes, what is your religion?
Do you have any religious practices or beliefs? If yes, what are they?
Is religion significant in your family's life? Does this help when you're in a difficult situation?
Does working on with your beliefs assist you in coping with difficulties? In what way/s?
Do you practice any natural or traditional medicine?