FUNCTIONAL HEALTH PATTERS

ASSESSMENT TOOL
Student’s Name: _______________________
Date: _________
Patient’s Name________________Male_________Female___________Age_____________
Medical Diagnosis____________________________________________________________
1. HEALTH PERCEPTIONAL-HEALTH MANAGEMENT
Past Medical History:
Illness: ___________________________________________________________________
Surgery: __________________________________________________________________
History of chronic disease: ___________________________________________________
Immunization History: __________Tetanus _______Pneumonia _______Influenza______
MMR _______Polio ________Hepatitis B ______
Use of Tobacco: ____None-Quit (date_______‹1ppd___1-2ppd_____›2ppd______Pks/yr.___
Alcohol: Amount/ Type: ___________________ Date of last drink_____________________
Frequency of use_________________________
Other drug: Amount/ Type: _________________ Frequency of use: ____________________
Medication (Prescription/ Nonprescription)
Name Dose Frequency of Use Last Dose

Allergies____________________________________________NKA___________________
Perception of Health: ________________Good ________ Fair _________ Poor__________
Health Management Habits: Exercise on a regular basis? __________Yes _____________No
Follow prescribed regimen? _________Yes ________No
Safety: ____Special Equipment ________Precautions: __________Side rails _____Restraints
Question for the following: Breast/ testicular self-examination, safe working
conditions_________________________________________________________________
Home Health: Safe environment in home i.e., access to home (strains): Cleanliness, health issue
observed: ______________________________________________________________
___________________________________________________________________________
2. NUTRITIONAL-METABOLIC
____________Not Assessed
_______Ht. ______Wt. ____ Type of diet/Restrictions: _________Regular ______Low salt
______Diabetic __________Othe Supplements _____________________
Appetite _____Normal ____Increased ______Decreased _____Decreased taste _____Food
Intolerance: _________Nausea ________ Vomiting Described: ______________________
__________Swallowing difficulties __________gag reflex _________Chewing difficulties
Feeding: _______ Self _________Assisted
Condition of mouth: ____________Pink _________Inflamed _________Moist _______Dry.
_________Lesions/ Ulcerations describe ____________________Teeth/ Gums _________
_________Dentures _______Upper (Partial/full) ______Lower (Partial/full) ______IV fluids
Type/amount________________________________________________________________
Insertion Site: _______________________________________________________________
___________NG _______________ Gastrostomy
Skin Condition:
________ Color: pallor, pink, jaundice, cyanotic, ruddy
________ Temperature: warm, cool, hot
________ dry, moist, clammy, diaphoretic
________ Edema: pitting/non-pitting
________ Turgor: good, poor, tending.
________ Pruritis
________intact________ bruises/lesions describe: (size, location) _____________________
________Body temperature” ________ axillary ________ oral ________ rectal
3. ELIMINATION
________ Not Assessed
Bowel Habits
Describe: __________________________________________________________________
(Consistency, color, amount, frequency)
________#BM’s/day ________Date of last BM
________ Constipation ________ Diarrhea ________ Incontinence
Bladder Habits Describe: ___________________________________ (color, clarity, amount)
________Frequency _____Dysuria ______Nocturia ________ Urgency ________ Hematuria
________Retention ________Burning ______________ Hesitancy ____________ Pressure
incontinence: ________No ________ Yes ________ Daytime ________Nighttime.
________ Occasional ________ Difficulty delaying voiding.
Assistive Devices: ________ Intermittent catheterization _____________ Indwelling catheter
________ External catheter
Ostomy: type: ________
Inspect Abdomen: ________ symmetry ________ Flat ________Rounded ________ Obese.
Auscultate Abdomen: _______normal bowel sounds____ Hypoactive ________Hyperactive.
Palpate abdomen: ________soft __________firm __________ tendered ________ distended
4. ACTIVITY-EXERCISE
________ Not Assessed
A. Musculoskeletal: ________ tremors ________ atrophy ________ swelling
Self-Care Ability: 0= Independent 1=Assistive device 2=Assistance from others
3=Assistance from person and equipment 4=Dependent/Unable
0 1 2 3 4
Eating
Bathing
Dressing
Toileting
Bed Mobility
Transferring
Ambulating
Stairs
Shopping
Cooking

Assistive Devices: _____None ______Crutches ________Bedside commode _______Walker

________cane ________splint/brace________wheelchair________thers________________
Gait: ________normal ________Abnormal_______________________________(describe)
Range of Motion ________normal ________limited________________________(describe)
Posture: ________normal ________Kyphosis ________Lordosis ________Scoliosis
Deformities: ________No________ Yes: _________________________________(describe)
Amputation___________________________Prosthesis_____________________________
Physical Developmental Assessment: _____________ normal _________ abnormal describe:
________________________________________________________________
B. CARDIOVASCULAR
________Not Assessed
Pulse: ________regular ________irregular________ strong ________weak
________radial rate ________apical rate
Blood Pressure: ________standing ________ lying ________sitting.
Extremities: Temperature: ________ cold ________cool ________warm ________hot
Capillary Refill: ________brisk ________sluggish
Color: ________________________________________________________(describe)
Homan’s Sign: ________ Negative ________ Positive
Nails: ________ Normal ________Thickened ________ Other: ________
Hair Distribution: ________ normal ________ abnormal _______________(describe)
Pulses: ________ Femoral ________ Popliteal ________ post-tibial ________ Dorsalis
________ Palpable ________ Palpable but weak ________ not palpable
Claudication: ________ Yes ________ No
C. RESPIRATORY
________Not Assessed
Inspect chest: ________ Symmetrical ________ Asymmetrical.
Respirations rate: ________deep________ Shallow ________ abdominothoracic.
apnea________ dyspnea at rest________ Orthopnea ________ dyspnea on exertion.
Cough: dry/productive ________________________________________________________
________ Sputum: (describe): __________________________________________________
Auscultate chest: ________ crackles ________rhonchi ________ friction rub ____________
Wheezing (describe)__________________________________________________________
Other: ________ Chest tube ________tracheostomy
Oxygen:____________________________________________________________________
5. SLEEP-REST
________ Not Assessed
Usual Sleep Habits: ________ hours per night.
Feel rested after sleep ________Yes ________ No. Awakening during night ___Yes___ No
Insomnia ________ Yes ________ No
Methods used to promote sleep: medication: _______________________________________
________ Warm fluids ________ rituals: (bathing, reading, TV, music)
6. COGNITIVE-PERCEPTUAL
________ Not Assessed
Level of Consciousness:
_________ alert _________ lethargic _______drowsy______ stuporous ________ comatose
Mood (subjective): _____pleasant _____irritable _______calm ______happy _____euphoric
________anxious ________fearful ________ Other: ________________________________
Affect (objective): ______ Anger ____Sadness _____Joy ____ Disgust _____Fear_____ Flat.
Orientation Level: ________ Person ________Place ________Time ______Significant other
Memory: recent: ________ Yes ________ No Remote: ________ Yes ________ No
Pupils: ________ Size ________ Reaction (brisk/ sluggish)
Reflexes:
Grasps: ________ Right: strong/weak ________ left: strong/weak
Push/ Pulls: ________ right: strong/weak ________ left: strong/ weak
Other: ________ numbness ________ tingling
Pain: ________ Denies
Character___________________________________________________________________
Onset (Timing of onset) ___________________________since when __________________
________Location: describe: __________________________________________________
Duration: __________________________________________________________________
Exacerbations (what increases pain) _____________________________________________
Radiation: describe: __________________________________________________________
Relieving Factors ____________________________________________________________
Associated Factors ___________________________________________________________
________ Intensity: (0-10 scale)
Thought Content: ____________________________________________________________
Senses: Visual Acuity: ________WNL ________ glasses ________contacts ____blind (R/L)
Prosthesis: (artificial eye) R/L
Hearing: ________WNL ________ impaired (R/L) ________deaf (R/L) _______hearing aid
Touch: _________ WNL________ abnormal: describe ________tingling ________numbness
Smell ________ normal ________abnormal
Ability to: communicate: language spoken ______ read______ clear_____ articulate_____
Ability to make decisions ______easy ______moderately easy _______moderately difficult.
________ difficult (subjective)
7. SELF-PERCEPTION-SELF-CONCEPT
________Not Assessed
Appearance: ____calm ___anxious _____irritable ________ withdrawn ________restless
________ appropriate dress ________ hygiene
Level of anxiety: (subjective) Rate on 0-10 scale__________________________________
(Objective) face reddened: ________ No________ Yes
Answer Questions: ________readily ________ hesitantly
Usual view of self ________ Positive ________ neutral ______somewhat negative (subjective)
Body Image: Is current illness going to result in a change in body structure or function?
________ No ________ Yes describe: ______________________________(subjective)
8. ROLE-RELATIONSHIP
________ Not Assessed
Does patient live alone ________ Yes ________ no: With whom________________________
Married ________ Children_____________________________________________________
Occupation: _________________________________________________________________
Employment Status: ______employed ______shot-term disability _____long-tern disability
________retired ________ unemployed
Support System: ________ spouse ________neighbors/ friends ________ none
________ family in same residence ________ family in separate residence
Family: Interactions: (describe) ________________________________________________
Concerns about illness:________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Will admission cause significant changes in usual role?_______________________________
___________________________________________________________________________
Social activities: ________ Active ________ limited ________ none

Activities participated in: ______________________________________________________

Comfort in social situations (subjective) _________ comfortable __________ uncomfortable
Note any evidence of physical or psychosocial abuse is patient is dependent on others for care.
9. SEXUALITY-REPRODUCTIVE
________ Not Assessed
Female: ________ date of LMP ________ Para ________ Gravida ________ Pregnant
________Menopause ________ No ________ Yes. Type (if yes)_______________________
Contraception ________ No ________ Yes. Type (if yes)_____________________________
History of vaginal bleeding ________ No ________ Yes (describe) _____________________
History of sexually transmitted disease ________ No ________ Yes: ____________________
Male: History of Prostate problems ________ Yes ________ No. History of penile discharge,
Bleeding, lesions: ________ No ________yes (Describe)_____________________________
___________________________________________________________________________
Last prostate exam: _____________________________
History of sexually transmitted disease ________ No ________ Yes: ____________________
Both: Problems with sexual functioning? __________________________________________
Sexual concerns at this time? ____________________________________________________
10. COPING-STRESS TOLERANCE
________ Not Assessed
Overt signs of stress (crying, wringing of hands, clenched fists)
Describe:
__________________________________________________________________________
Question patient regarding:
Primary way you deal with stress?
__________________________________________________________________________
Concerns regarding hospitalization/ illness: (financial, self-care) ________________________
Major loss within last year ________ Yes________ No
Describe:
___________________________________________________________________________
11. VALUE-BELIEF
________ Not Assessed
Religion: ____ Muslim _____ Hindu ____ Christian _____ None _____ Others: __________
Religious Restrictions: _______________________________________________________
Religious Practices:__________________________________________________________
Concerns related to ability to practice usual spiritual or religious customs?
________ No ________ Yes (describe) ___________________________________________