QUESTIONNAIRE

BIOGRAPHIC DATA: Name: Address: Gender: Age: Marital Status: Occupation: Religion:

CHIEF COMPLAINT: 1. Can you tell me the reason why you came here today?

HISTORY OF PRESENT ILLNESS: 1. 2. Where is the exact location in your body can you feel the pain? Where were you when you felt the pain?

3. In a scale of 1-10, 1 is the lowest and 10 is the highest, rate the pain that you felt when the problem occurred. 4. 5. 6. 7. 8. 9. When did it first occur? How long does it occur? How often does it occur? What were you doing when the problem occurred? What makes the pain worse? How did you manage the pain?

10. How does this problem affect your daily activities? 11. What are the associated symptoms you felt when the problem occurred?

PAST HEALTH HISTORY: 1. 2. 3. 4. 5. 6. 7. 8. 9. What childhood illnesses did you encounter? What immunizations did you already receive? When was your last immunization? Do you have any allergies? If yes, what causes those allergies? How do you treat your allergic reactions? Did you ever have serious injuries brought by accidents? When did it happen? Where did it happen? What type of injury did you encounter?

10. What treatments did you receive? 11. Is there any complication that makes it worse? If yes, what are those? 12. Did you ever confine in a hospital? If yes, when was that? 13. What is the reason of your hospitalization? 14. Are you taking medicines at present? If yes, what kind of medicines are those?

FAMILY HEALTH HISTORY: 1. 2. Do you have common diseases within your family? If yes, what are those diseases? Who among the family members have that disease?

GORDONS FUNCTIONAL PATTERN: Health Perception/Health Management How do you perceive your health? Do you see yourself as a healthy individual?

How do you manage/handle your health? If youre sick, whats the first thing that you do? If youre well, how does you maintain being healthy?

Nutritional-Metabolic Do you follow the eating pattern 3 meals a day? What kind of foods are you eating during meals? Breakfast, lunch and supper? What do you usually drink? How many glasses of water do you drink every day? Do you use a cup, glass or mug? Do you drink liquor? If yes, what kind of liquor? How often do you drink liquor? Do you know your weight? If yes, then what is your weight?

Elimination How many times do you urinate in a day? Do you have difficulty in urinating? What is the color of your urine? Can you estimate the amount of your urine? What is your estimation? How often do you move your bowel? Do you see something different from your bowel? What is the color of your bowel? Do you have difficulty in defecating?

Activity-Exercise What are the hygienic activities that you do?

Do you exercise daily? What time of the day do you exercise? How long do you exercise? What kind of exercise do you do? What are the activities that you do in your job or occupation?

Cognitive-Perceptual Do you have sensory problems? Do you wear eyeglasses? Do you wear hearing aids? Whats the date today? Whats the time? How about the place where you are now? Do you know the people do you spent your time with?

Sleep-Rest Do you have any activities before going to sleep? If yes, what are those? Do you have any difficulty in sleeping? How many hours do you sleep? What time do you sleep at night? What time do you wake up in the morning? Do you take afternoon naps?

Self-Perception/Self-Concept How do you describe yourself?

What are your strengths? Weaknesses? Do you consider yourself as a well-groomed/ neat person? Are you comfortable with your appearance?

Role-Relationship Can you describe your relationship with your family? Who among the members of the family are you close with? Can you describe your relationship with your friends? Peers? What role do you perform in your family? Friends? Peers? Do you have positive role models for these roles in the family? Friends? Peers? Which relationships are most important for you at this present? Are you going through any big changes in role or relationship? What are they?

Sexuality-Reproductive When were you circumcised? --Do you have regular menstrual cycle? If not, how long is your menstrual cycle? How many pads do you consume in a day? Do you experience dysmenorrhea? --Do you have experience involving sexual intercourse? Are your sexual desires satisfied by doing sexual intercourse with your partner? Do you have plans having children?

Coping-Stress/Coping-Tolerance

What do you usually do if youre stressed? Do you keep your problems with yourself? If no, to whom do you run in times of stress? Can you give me some reasons that results your stress?

Value-Belief What religion do you belong? Do you have any special practices that involve in your religious or any other group? Are there any other groups that you are involved with? Cultural, ethnic, regional? What principles did you learn during childhood that is still important to you today?

REYNABEL PAZZIUAGAN ANGELIKA DOLOZON BSN 2C