St.

Paul University Philippines

TUGUEGARAO CITY, CAGAYAN VALLEY 3500 SCHOOL OF HEALTH SCIENCES

HEALTH HISTORY

Biographic Data Name:_____________________________________Gender:____Age:___Marital status:______ Birthday:_________ Birthplace:___________________________ ___Religion:______________ Address:___________________________________Nationality:___________Citizenship:_____ Occupation:___________________ Health Care Resources:____________ Chief Complaint a. What is troubling?

b. Do you feel any discomfort?

History of Present Illness a. What are the symptoms?

b. When did those symptoms begin?

c. How often it occurs?

d. Is this the first time you experienced this problem?

e. In the onset of symptoms, is it sudden or gradual?

f. Kindly specify to me the parts of your body that are being affected?

g. If you rate the pain you experienced from 1 to 10, what number would it corresponds? h. Are there things that when you do such, the pain was being aggravated or alleviated?

i. Did you take any medications? j. Did you consult a doctor?

Past Health History a. Have you encountered childhood illnesses? Can you specify them?

b. Did you receive any vaccines in your childhood? Cite some of those.

c. Did you have any allergies on food, drugs, animals, or other environmental agents? If so, what is the type of reaction that occurs?

d. When did the last time you encountered an accident/injury? When did it happen? What part of your body was affected? What kind of accident or injury was it? What is the treatment you received?

e. Have you been hospitalized before? Where hospital have you been confined? What is the name of the hospital? What is the reason for hospitalization?

f. Have you undergone any surgical procedure/operations? If so, what are these?

g. If you encounter such problems, what medicine do you take?

h. Do you have any maintenance medicines?

Family Health History a. What genetically linked or common diseases that runs in your family?

St. Paul University Philippines

TUGUEGARAO CITY, CAGAYAN VALLEY 3500 SCHOOL OF HEALTH SCIENCES

GORDONS FUNCTIONAL HEALTH PATTERN

Name:_____________________________________Gender:____Age:___Marital status:______ Birthday:_________ Birthplace:___________________________ ___Religion:______________ Address:___________________________________Nationality:___________Citizenship:_____ Occupation:___________________ Health Care Resources:____________

Health Perception-Health Management Pattern a. What is a health for you?

b. What do you do to take care of your health?

c. What are the different ways you perform to maintain proper hygiene? Do you take a bath every day? How many times you brush your teeth?

d. What do you usually do when you're sick? Do you take over-the-counter medications? Do you take medications which are not prescribed from any physicians?

e. Where do you go for healthcare?

f. Do you use cultural remedies for illness? If so, specify them.

Nutritional-Metabolic Pattern Height:_________ Weight:________ a. How many times you eat daily? What is your regular meal? How many cup of rice?

b. How many glasses of water do you take in a day?

c. What are your favorite foods?

d. Do you take snacks in between meals? What kind of snacks?

e. Do you have any allergy? If so, what type of reaction that occurs?

f. Are you taking any dietary supplements? Specify them.

g. Do you have any skin diseases?

Elimination Pattern a. How many times you urinate every day? Do you feel any pain on your urination? Kindly describe to me the color of your urine?

b. How many times you defecate in a week? Kindly describe to me the color of your stool? Is it hard or soft?

c. Do you use any laxatives when you are experiencing difficulties?

Activity-Exercise Pattern a. What are your daily activities?

b. What do you usually do during your free time?

c. Are you performing exercises or any sort of it? What are those? How often do you exercise?

d. How do you usually feel after performing such activity?

e. Do you experience any unusual things?

f. Is there any difficulty in your breathing?

g. Do you experience any muscle ache?

h. Do you feel dizzy?

i. Do you get easily tired?

Sleep-Rest Pattern a. Do you think you have a healthy sleep pattern?

b. How many hours do you sleep at day/night?

c. Do you sleep continuously? Or are there interruptions in between your sleep?

d. Do you get up at night to go to the bathroom? e. What time do you sleep at night? f. What time do you wake up in the morning? g. Are you taking sleeping pills?

Cognitive-Perceptual Pattern a. Are you having a monthly check up with your different senses? b. Can you see things clearly? c. Are you nearsighted/farsighted? d. How long are you using your eyeglasses/contact lenses, since when? e. Do you hear things clearly? f. Can you distinguish one smell from another? g. Can you decipher the four different tastes?(sweet, bitter ,salty sour) h. Do you have difficulties in remembering things, where do you put that thing?

Self-perception-Self-concept Pattern a. How do you feel about yourself?

b. Are you contented on being you?

c. Kindly tell me what are your greatest achievements as of now?

d. Do you believe in yourself? How high is your self confidence?

e. Are you looking to yourself as superior to others?

f. Kindly tell me what are your strengths/weaknesses?

g. What are your talents?

h. What are your fears in life?

i. Which do you prefer most of the time, to be alone or to be with many people? Why?

Role-Relationship Pattern a. How is your relationship with your family? (to your brothers, sisters, parents)

b. How is your relationship with your friends?

c. Do you feel comfortable at your house?

d. Are you comfortable with your role in your family?

f. How do you fulfill your responsibilities at your house?

Sexuality-Reproductive Pattern a. Do you have any problem with your reproductive system?

b. Are you married? If yes, how often do you have sexual intercourse?

c. Are you satisfied every after the activity?

d. Do you have a regular menstrual period? e. During those times, are you having a dysmenorrhea ? What do you usually do to relieve the pain?

f. If you are single ,what do you usually do to satisfy your needs as a male?

Coping-Stress Tolerance Pattern a. What do you do when you feel stressed? Do you eat too much, take a nap, cry, hit yourself or what?

b. Are you fund of attending 'gimiks' or any recreational activities? What are those? Does it help you feel relieved?

c. What are the things that give/make you fatigue?

Value-Belief Pattern a. Do you believe that there's god? Why?

b. Do you communicate with him? Through what ?

c. Are there any superstitious beliefs you usually do related to health? What are these?

d. In your religion, are there medical practices which are not allowed?