Demographic Profile

Date: Time:
Name of Patient: __________________________________________________________
(Last Name) (First Name) (Middle Name)
Address: __________________________________________________________________
Date of Birth: _______________ Age: __________ Sex: ___________
Contact Person: _________________________________
Relationship: ________________ Contact no.: ________________

Vital Signs:

Temperature: ________________
Pulse Rate: ____________ Bpm; Regular ( _____ ) Irregular ( _____ )
Respiratory: ___________ Cpm
Blood Pressure: ________ Hhmmg

Weight: ___________
Height: ____________

Gordon’s Functional Health Pattern Assessment Tool

1. Health perception and health management

a. Kamusta naman po ang kalusugan ng pamilya po ninyo at
ikaw?_________________________________________________________
_______________________________________________________________
_______________________________________________________________
b. Paano mo po napapanatili ang iyong kalusugan? Umiinom po
ba kayo ng mga inuming may alkohol o naninigarilyo po ba
kayo? ________________________________________________________

c. Gaanon po kayo kadalas bumibisita sa iyong doktor? Binibigyan

mo ba ng priyoridad at sinusunod ang payo ng iyong mga
health-care providers? ________________________________________
_______________________________________________________________
_______________________________________________________________
2. Nutrition and metabolism
a. Maaari mo bang ilarawan ang mga gawi sa pagkain ng iyong
pamilya? Sa palagay mo po ba ay kumakain ng malulusog na
mga pagkain ang iyong pamilya?_____________________________
_______________________________________________________________
_______________________________________________________________

b. Sa tingin mo ba ikaw ay sobra o kulang sa timbang? Mayroon

bang anumang pagbigat o pagbagwas nito na hindi
maipaliwanag?_______________________________________________
_______________________________________________________________
_______________________________________________________________

3. Elimination
a. Paano ang dalas, kakulangan sa ginhawa, at kontrol na mga
isyu na iyong naranasan sa pag ihi at at pag bawas po?
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

4. Activity and exercise

a. Nag-eehersisyo ka po ba? Ano pong klaseng ehersisyo ang
ginagawa mo at gaano mo ito kadalas gawin?
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

b. Ano ang gusto mong gawin sa iyong libreng oras? Aling isports
ang sinasalihan mo? __________________________________________
_______________________________________________________________
_______________________________________________________________

5. Cognition and Perception

a. Nahihirapan ka bang marinig ang ibang tao?__________________
 _______________________________________________________________
_______________________________________________________________

b. Mayroon ka bang mga problema sa paningin? Nakakakuha ka

ba ng regular na pag check-up sa mata?______________________
_______________________________________________________________
_______________________________________________________________

c. Paano mo gustong matuto? Alin ang mas natututo ka: visual o

auditory aid? Nahihirapan ka ba sa pag-aaral? ________________
_______________________________________________________________
_______________________________________________________________

6. Sleep and rest

a. Itinuturing mo ba ang iyong sarili na nakapagpahinga nang
maayos at may kakayahang gawin ang iyong mga
pang-araw-araw na gawain?__________________________________
_______________________________________________________________
_______________________________________________________________

b. Gaano ka nakakatulog? Gumagamit ka ba ng anumang tulong

upang matulungan kang matulog?____________________________
_______________________________________________________________
_______________________________________________________________

c. Nakakaramdam ka ba na nakapag pahinga ka ng maayos at

handa ka nang harapin ang araw sa iyong paggising?__________
_______________________________________________________________
_______________________________________________________________

7. Self-perception and self-concept

a. Kadalasan, maganda ba ang pakiramdam mo at confident sa
iyong sarili?____________________________________________________
_______________________________________________________________
_______________________________________________________________
 b. Nararamdaman mo na ba na sumuko ka na sa mahihirap na
karanasan?___________________________________________________
_______________________________________________________________
_______________________________________________________________

8. Roles and relationships

a. Sino ang kasama mo sa bahay? Ikaw ba ay nag-iisa lamang,
kasama mo po ba ang iyong pamilya?_________________________
_______________________________________________________________
_______________________________________________________________

b. Nakikipag-ugnayan ka po ba sa iba pang tao sa labas ng

trabaho o paaralan?__________________________________________
_______________________________________________________________
_______________________________________________________________

9. Sexuality and reproduction

a. Paano mo naitugma ang mga plano at karanasan mo sa
pagkakaroon ng mga anak?___________________________________
_______________________________________________________________
_______________________________________________________________

b. Mayroon ka bang anumang sakit o dysfunction ng reproductive

system? ______________________________________________________
_______________________________________________________________
_______________________________________________________________

10. Coping and stress tolerance

a. Sino ang higit na nakakatulong saiyo sa pag-uusap ng mga
problema? Ang mga madalas ba silang available sa iyo?
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
 b. Gumagamit ka ba ng anumang mga gamot, droga, o alkohol,
kamakailan lamang?__________________________________________
_______________________________________________________________
_______________________________________________________________

11. Values and belief

a. Mahalaga ba ang relihiyon sa buhay mo at ng iyong pamilya?
Nakakatulong ba ito kapag nahaharap ka sa mahihirap na
sitwasyon?____________________________________________________
_______________________________________________________________
_______________________________________________________________

b. Pwede mo bang ilalarawan mo ba sa akin ang iyong mga plano

para sa hinaharap? Sa pangkalahatan, nakukuha mo ba ang
gusto mo sa buhay?___________________________________________
_______________________________________________________________
_______________________________________________________________