Patients profile GORDONS FUNCTIONAL HEALTH ASSESSMENT

Name: I. Health Perception- Health Management Pattern

Birth Date: 1. Hx:
Birthplace: a. How has general health been?
Religion: b. Any colds in past year?
Address: When appropriate: absences from work?
Educational Attainment: c. Most important things you do to keep healthy?
Occupation: Think these things make a difference to health?
Ethnic Group: Use of cigarettes, alcohol or drugs?
Impression/Dx: Breast Self-examination?
Date of Admission: d. Accidents (home, work, driving]?
Attending Physician: e. In past, been easy to find ways to follow suggestions from physician or nurses?
Age: f. When appropriate: what do you think caused this illness?
Sex: Actions taken when symptoms perceived?
Civil Status: Results of action?
Height: g. When appropriate: things important to you in your health care? How can we be
Weight: most helpful?
Vital Signs 2. Examination-general health appearance
Temp: II. Nutritional-Metabolic Pattern
HR: 1. Hx:
RR: a. Typical daily food intake? (Describe.]
BP: Supplements (vitamins, type of snacks?]
Clients History b. Typical daily food intake? (Describe].
*General Health Status: c. Weight loss or gain? (Amount]
Appearance: Height loss or gain? (Amount]
Appear Stated Age? d. Appetite?
Are face and body symmetrical? e. Food or eating:
Obvious deformities? Discomfort?
Look well, ill or in distress? Swallowing?
Hygiene and Dress: Diet restrictions?
Observe clothes, hair, nails, and skin. f. Heal well or poorly?
What is the pt wearing? g. Skin problems:
Is it appropriate for age, gender, culture and weather? Lesions?
Is it clean and neat? Dryness?
Does it fit? h. Dental problems?
Any breath or body odors? 2. Examination
Is the skin clean and dry? a. Skin:
Are the hair and nails well kempt and clean? Bony prominences?
Observe skin tones and symmetry. Lesions?
Note any redness, pallor, cyanosis, or jaundice. Color changes?
Observe for any lesions or variations in pigmentation Moistness?
Note amount, texture, quality, and distribution of hair. b. Oral mucous membranes:
Body Structure and development. color?
Is physical and sexual development consistent with stated age? Moistness?
Is the patient obese or lean? Lesions?
How tall is the patient? c. Teeth: General appearance and alignment?
Are body parts symmetrical? Dentures?
Is the patient barrel chested? Cavities?
Note fingertips. Missing teeth?
Are there any joints abnormalities? d. Actual weight & height
Behavior e. Temperature
Is the patient cooperative? f. Intravenous feeding-parenteral feeding (specify]?
Is affect animated or flat? III. Elimination Pattern
Does the patient appear anxious? 1. Hx:
*Past Medical Problems: a. Bowel elimination pattern? [Describe.]
Frequency?
*Hospitalizations and Surgery: Character?
Discomfort?
*Immunizations: Problems in control?
c. Excessive perspiration?
*Childhood Illnesses: Odor problems?
d. Body cavity drainage, suction, and so on? [Specify]
*History of patients illness 2. Examination- when indicated: examine excreta or drainage color and
Onset consistency.
Location IV. Activity-Exercise Pattern
Duration 1. Hx:
Characteristic a. Sufficient energy for desired or required activities?
Associated/Aggravating factors b. Exercise pattern?
Relieving factors Type?
Timing Regularity?
Severity c. Spare-time [leisure] activities?
*Chief complaints Child: play activities?
d. Perceived ability [code for level] for: c. Nervous [5] or relaxed [1]; rate from 1 to 5
Feeding____Dressing____Coking____ D. Assertive [5] or passive [1]; rate from 1 to 5
Bathing____Grooming____Shopping____ VIII. Roles-Relationship Pattern
Toileting_____General Mobility____ 1. Hx:
Bed mobility____Home maintenance_____ a. Live alone?
Functional Level Codes: Family?
Level O: full self-care Family structure [diagram]?
Level I: require use of equipment or device b. Any family problems you have difficulty handling (nuclear or extended]?
Level II: requires assistance or supervision from another person c. Family or others depend on you for things?
Level III: requires assistance or supervision from another person and equipment or How managing?
device d. When appropriate: How family or others feel about illness or hospitalization?
Level IV: is dependent and does not participate e. When appropriate: Problems with children?
2. Examination Difficulty handling?
a. Demonstrated ability [code listed above] for: f. Belong to social groups?
Feeding____Dressing____Coking____ Close friends?
Bathing____Grooming____Shopping____ Feel lonely [frequency]?
Toileting_____General Mobility____ g. Things generally go well at work? [School?]
b. Gait___Posture____Absent body part? [Specify] h. When appropriate: Income sufficient for needs?
c. Range of motion [joints] ______
Muscle firmness_____ i. Feel part of [or isolated in] neighborhood where living?
d. Hand grip___ Can pick up a pencil?_____ 2. Examination
e. Pulse [rate] _____[rhythm]_____ Breath sounds____ a. Interaction with family member[s] or others [if present].
f. Respirations [rate] _____ [rhythm] ____ IX. Sexuality-Reproductive Pattern
Breath sounds____ 1. Hx:
g. Blood pressure_____ a. When appropriate to age and situation: Sexual relationships satisfying?
h. General appearance [grooming, hygiene, and energy level] Changes?
V. Sleep-Rest Pattern Problems?
1. Hx: b. When appropriate: Use of contraceptives?
a. Generally rested and ready for daily activities after sleep? Problems?
b. Sleep onset problems? c. Female: When menstruation started?
Aids? Last menstrual period?
Dreams [nightmares]? Menstrual proles?
Early awakening? Para?
c. Rest-relaxation periods? Gravida?
2. Examination 2. Examination
a. When appropriate: Observe sleep pattern. a. None unless problem identified or pelvic examination is part of full physical
VI. Cognitive-Perceptual Pattern assessment.
1. Hx: X. Coping-Stress Tolerance Pattern
a. Hearing difficulty? 1. Hx:
Hearing aid? a. Any big chances in your life in the last year or two?
b. Vision? Crisis?
Wear glasses? b. Whos most helpful in talking things over?
Last checked? Available to you now?
When last changed? c. Tense or relaxed most of the time?
c. Any change in memory lately? When tense, what helps?
d. Important decision easy or difficult to make? d. Use of any medicines, drugs, alcohol?
e. Easiest way for you to learn things? e. When [if] have big problems [any problems] in your life, how do you handle
Any difficulty? them?
f. Any discomfort? f. Most of the time is this [are these] way[s] successful?
Pain? 2. Examination: None.
When appropriate: How do you manage it? XI. Values-Beliefs Pattern
2. Examination 1. Hx:
a. Orientation a. Generally get things you want from life?
b. Hears whisper? Important plans for the future?
c. Reads newsprint? b. Religion important in life?
d. Grasps ideas and questions [abstract, concrete]? When appropriate: Does this help when difficulties arise?
e. Language spoken. c. When appropriate: Will being here interfere with any religious practices?
f. Vocabulary level. Attention span. 2. Examination: None
VII. Self-PerceptionSelf Concept Pattern 3. Other concerns
1.Hx: a. Any other things we havent talked about that you would like to mention?
a. How describe self? b. Any questions?
Most of the time, feel good [not so good] about self?
b. Changes in body or things you cant do? Problem to you?
c. Changes in way you feel about self or body [since illness started]?
d. Things frequently make you angry?
Annoyed?
Fearful?
Anxious?
e. Ever feel you lose hope?
2. Examination
a. Eye contact. Attention span [distraction].
b. Voice and speech pattern. Body posture -kylelaride-
Patients profile Patients profile
Name: Name:
Birth Date: Birth Date:
Birthplace: Birthplace:
Religion: Religion:
Address: Address:
Educational Attainment: Educational Attainment:
Occupation: Occupation:
Ethnic Group: Ethnic Group:
Impression/Dx: Impression/Dx:
Date of Admission: Date of Admission:
Attending Physician: Attending Physician:
Age: Age:
Sex: Sex:
Civil Status: Civil Status:
Height: Height:
Weight: Weight:
Vital Signs Vital Signs
Temp: Temp:
HR: HR:
RR: RR:
BP: BP:
FHT: FHT:
Meds: Meds:
Patients profile Patients profile
Name: Name:
Birth Date: Birth Date:
Birthplace: Birthplace:
Religion: Religion:
Address: Address:
Educational Attainment: Educational Attainment:
Occupation: Occupation:
Ethnic Group: Ethnic Group:
Impression/Dx: Impression/Dx:
Date of Admission: Date of Admission:
Attending Physician: Attending Physician:
Age: Age:
Sex: Sex:
Civil Status: Civil Status:
Height: Height:
Weight: Weight:
Vital Signs Vital Signs
Temp: Temp:
HR: HR:
RR: RR:
BP: BP:
FHT: FHT:
Meds: Meds:
Patients profile Patients profile
Name: Name:
Birth Date: Birth Date:
Birthplace: Birthplace:
Religion: Religion:
Address: Address:
Educational Attainment: Educational Attainment:
Occupation: Occupation:
Ethnic Group: Ethnic Group:
Impression/Dx: Impression/Dx:
Date of Admission: Date of Admission:
Attending Physician: Attending Physician:
Age: Age:
Sex: Sex:
Civil Status: Civil Status:
Height: Height:
Weight: Weight:
Vital Signs Vital Signs
Temp: Temp:
HR: HR:
RR: RR:
BP: BP:
FHT: FHT:
Meds: Meds:
Patients profile Patients profile
Name: Name:
Birth Date: Birth Date:
Birthplace: Birthplace:
Religion: Religion:
Address: Address:
Educational Attainment: Educational Attainment:
Occupation: Occupation:
Ethnic Group: Ethnic Group:
Impression/Dx: Impression/Dx:
Date of Admission: Date of Admission:
Attending Physician: Attending Physician:
Age: Age:
Sex: Sex:
Civil Status: Civil Status:
Height: Height:
Weight: Weight:
Vital Signs Vital Signs
Temp: Temp:
HR: HR:
RR: RR:
BP: BP:
FHT: FHT:
Meds: Meds: