Moquia, Roberta D.

BSN-1

Gordon’s Functional Health pattern Assessment

A. BIOGRAPHIC DATA

1. Name

2. Address

3. Age

4. Gender

5. Date of Birth – Age as of Last Birthday

6. Place of birth

7. Ethnic group (Minority)

8. Primary Dialect spoken - Only one!!

9. Marital Status

10. Educational

11. Occupation (not student)

12. Religious orientation – Religious Sect

13. Health Care financing and usual source of medical care – Where do you get financial Health

14. Income (Allowance)

B. PAST HEALTH HISTORY

1. Childhood diseases (Specify immunizable and chronic(relapse) (significant) diseases, Age when disease

acquired, interventions done, residual effects of disease, be careful with spelling of disease)

2. Immunizations- name and doses, consider secondary sources)

3. Allergies • drugs • food • others - description of reaction, treatment regimen, compliance, frequency of

attacks

4. Accidents and Injuries – Specify minor and major injuries that required medical attention

5. Hospitalizations and medications (include Self-prescribed)- Specify year, disease, outcome

7. Foreign Travel – Specify all travels to any countries made during the past year

8. Local Travel – to identify visit endemic Areas during the past years
C. FAMILY HISTORY OF ILLNESS (insert genogram)

1. Health and ages of parents, siblings, children, or ages at death and causes illness in the family similar

to the patient’s – IF DATA IS UNVAILABLE, WRITE “DATA UNAVAILABLE.”

2. Presence of any hereditary diseases: (FOCUS ON HEREDITARY DISEASES) familial incidence of heart

disease, rheumatic fever? Tuberculosis? Diabetes Mellitus? Mental illness?

3. Others? SUCH AS PRESENCE OF HYPERTENSION, CONGENITAL CONDITIONS

FUNCTIONAL HEALTH PATTERNS

D. HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERN

1. How has the general health been? How do you rate your own health? – MAKE SURE TO EXPLAIN THE

RATING DONE BY THE CLIENT.

2. HOW DO YOU PERCIEVE A HEALTHY PERSON, DO YOU CONSIDER YOURSELF AS HEALTHY PERSON?

What do you consider healthy about you? What are your health goals? WHAT ARE YOUR METHODS TO

ACHIEVE THEM?

3. Do you have routine physical examination? If yes how often? IF NO, EXPLORE REASONS FOR NOT

HAVING A ROUTINE EXAMINATION OR FOR STOPPING AND

4. In the past year how many times have you seen a health care provider? For what reasons?

5. In the past, has it been easy to find ways to follow things nurses/doctors suggest? CITE INSTANCES

WHEREIN YOU ARE ABLE OR NOT ABLE TO FOLLOW THESE INTERVENTIONS. EXPLORE REASONS WHY

UNABLE TO FOLLOW SUGGESTIONS.

E. NUTRITIONAL AND METABOLIC PATTERN

1. Knowledge about basic nutrition? Awareness on healthy food and fluid choices?

2. Food or eating discomforts? Diet restrictions?

3. 3 day diet recall (on a typical day, feasts not included) - TYPE OF FOOD,QUANTITY (AMOUNT AND

SIZE), METHOD OF COOKING, INCLUDE FLUIDS,TIME OF EATING

4. Sudden change in weight (loss/ gain)?Amount?

5. SUPPLEMENTS TAKEN, DOSES, PRESCRIBE

F. ELIMINATION PATTERN

1. Bowel elimination pattern.When do you usually have a bowel movement Frequency? Do you usually go
to the toilet when there is an urge to defecate? Any recent environmental changes? Characteristics (color,

texture, odor shape and consistency)? Any changes of these recently? Discomfort/pain? Any significant

change in the usual pattern?

2. What problems have you had or do you now have with your bowel movements (constipation, diarrhea,

excessive flatulence, seepage, or incontinence) When and how often does it occur? What do you think

causes it (food, fluids, exercise, emotions, medications, diseases, surgery)? What have you tried to solve

the problem, and how effective was it? Do you experience any increase in abdominal pressure/ feeling of

rectal fullness/pressure

3. Knowledge regarding normal defecation pattern? Knowledge to maintain normal defecation pattern?

What routines or practices do you follow to maintain your usual defecation pattern? Is it Effective? How

do you think these practices affect your defecation pattern? Do you use natural aids such as specific

foods or fluids, laxatives, or enemas to maintain elimination? What foods do you believe affect

defecation? Are you experiencing any stress? Do you think it affects your defecation pattern? How?

4. Urinary elimination pattern. Describe. Frequency? Has this pattern change recently? Do usually urinate

whenever you feel the urge? Any feelings of urgency? Hesistancy? Characteristics (color, clarity, odor)?

Discomfort/pain? Problems in control? (Approximated amount in mL per day)? Passage of small amounts

of urine? Voiding at intervals that are more frequent? Trouble getting to the bathroom in time or feeling

an urgent need to void? Difficulty starting urine stream? Frequent dribbling of urine or feeling of bladder

fullness associated with voiding small amounts of urine? Reduced force of stream? Accidental leakage of

urine? If so when does it occur (when coughing, laughing, or sneezing; at night or during the day)? Past

urinary tract illness such as infection of the kidney, bladder or urethra; urinary calculi; surgery of kidney,

ureters, or bladder?

G. ACTIVITY-EXERCISE PATTERN

1. What are your usual hobbies? Are you able to find time and allot resources for your hobbies at

present?

2. Any recent changes in your activities? What brought about such changes?

3. Do you experience boredom at times? In which instances?

4 .What materials, equipment or resources for recreation and diversional activity are present in your

immediate environment?

10. Have there been changes in your diversional activity? Please elaborate. How are you adapting to
changes? Is there sudden weight loss/ gain?

Observe for: Flat affect, Disinterest, Inattentiveness, Restlessness, Crying, Withdrawal, Hostility

H. SLEEP AND REST PATTERN

1. Describe sleeping environment. Any problems? Concerns?

2. Any problem falling sleep?

3. How many hours of sleep do you usually have? What time do you usually sleeps?wakes up?

4. Any change in the pattern of sleep? Explore client’s perception regarding the possible reasons for

this. Should be maintained for one week,

5.What helps you sleep? (back rub, music or warm milk? Do you take sleep medications?)

J. SELF-PERCEPTION AND SELF-CONCEPT PATTERN

1. Are you a nervous person? Describe.

2. Has there been any major change in your life lately? Please leaborate on this/these change/s.

3. Are your feelings easily hurt? Why? How do you react on it?

4. Do you feel regretful, scared, distressed, apprehensive or fearful lately? What makes you feel so?

Does it affect you in any physical/ physiological way? How?

5. Would you consider that there is still a possibility that you can get help? If so, would you consider

yourself to be part of it?

K. ROLE-RELATIONSHIP PATTERN

1. Live alone? With family? (illustrate family diagram) Family structure? (Accdg to membership: Nuclear,

Extended, Single parent,etc.; Accdg to Authority: Patriarchal, Matriarchal, Egalitarian,Democratic )

Significant people in life? (What role do they (SO) play in the client’s life)

2. Describe relationship to each/other member of the family; how do you feel about them? When with

them, do you often feel happy, hurt, insecure, rejected, misunderstood, unloved, lonely? Note any

observable conflicts between members

3. Role/s assumed in the family. Fulfilled/ Any difficulty in performing your role/s? Why? (Who plays as

the role model in the family? Who guides you in doing your role/s) Any unrealistic role expectations? Are

the resources/your energy enough for you to perform your role/s?

4. Any family problems you have difficulty handling? (Alcohol/substance abuse by a member, any Physical
Disabilities of a member/presence of illness, problems in behavior, decisional conflicts) Explore.

5. How does your family usually handle problems? Effective or not? Cite examples (ways of coping), any

incidence of inappropriate expression of anger, blaming, criticizing, verbal abuse, lying) How do you

address such? Effective?

L. SEXUALITY-REPRODUCTIVE PATTERN

1. Are you comfortable with the gender to which you belong?

2. (For a female client) When did you have your first menstruation (menarche)?

3. When was your last menstrual period? Please describe the duration, (amount) number of pads

used per day, any associated discomfort and measures that would help relieve this (if any).

4. Is there any discomfort or problem with regard to your genitalia that you would like to share or is

significant that we note?

5. (For both male and female clients) If there are reproductive health concerns, do you feel the

need or at least make it a point to visit or consult a health care provider? If so, what are the

usual reasons why you seek medical consultation?

M. COPING-STRESS TOLERANCE PATTERN

1. Any big changes in your life in the last year or two?

2. Describe a stressful event for you?

3. How do you handle stress or pressure? Is it easy for you to admit problems, mistakes or weaknesses?

Are you usually defensive when being slighted? Explore. Give situations or scenario indicating defensive

behavior.

4. How do you usually cope with stressful situations? when faced with a stressful problem, do you see

yourself having full control of the situation?

5. How do you react to failures? How do you react when somebody offers you help or assistance?