Gordons Interview Form (MCN)
Gordons Interview Form (MCN)
Gordons Interview Form (MCN)
Vision
a. Visual acuity: Both eyes 20/___; Right 20/___; Left 20/___; Not
DEMOGRAPHIC DATA Date: ______________ Time: assessed___
Name: b. Pupil size: Right: Normal__ Abnormal__;
Address: Left: Normal__ Abnormal__
Age: c. Pupil reaction: Right: Normal__ Abnormal__;
B.place: Left: Normal__ Abnormal__
Gender:
Civil Status: 3. Hearing
Religion a. Not assessed__
Highest Educational Attainment: b. Right ear: WNL__ Impaired__ Deaf__; Left ear: WNL__ Impaired__
Occupation: Deaf__
Monthly budget c. Hearing aid: Yes__ No__
-Injuries: 10. Any enlarged lymph nodes in the neck? No__ Yes__ Location and size:
-Hospitalization: 11. General appearance:
a. Hair:
-Operation: b. Skin:
-Allergies: c. Nails:
-Medication: d. Body odor:
-Immunization SUBJECTIVE
-Last Examination 1. How would you describe your usual health status?
Good__ Fair__ Poor__
Obstetric Gyne 2. Are you satisfied with your usual health status?
-LMP: Yes__ No__ Source of dissatisfaction:
-Menarche: 3. Tobacco use? No__ Yes__ Number of packs per day? Aware of the effects? __
-Menstruation: 4. Alcohol use? No__ Yes__ How much and what kind? Aware of the effect? ____
5. Street drug use? No__ Yes__ What and how much?
6. Any history of chronic disease? No__ Yes__ Describe:
HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN 7. Immunization history: Tetanus__ Pneumonia__ Influenza__ MMR__ Polio__
Hepatitis B__
OBJECTIVE 8. Have you sough any health care assistance in the past year? No__ Yes__ If
1. Mental Status (indicate assessment with a ) yes, why?
a. Oriented__ Disoriented__ 9. Are you currently working? No__ Yes__ How would you rate your working
Time: Yes__ No__; Place: Yes__ No__; Person: Yes__ No__; conditions? (e.g. safety, noise, space, heating, cooling, water, ventilation)?
b. Sensorium Excellent__ Good__ Fair__ Poor__ Describe any problem areas:_
Alert__ Drowsy__ Lethargic__ Stuporous__ Comatose__ 10. How would you rate living conditions at home? Excellent__ Good__ Fair__
Cooperative__ Combative__ Delusional__ Poor__ Describe any problem areas:
c. Memory 11. Do you have any difficulty securing any of the following services?
Recent: Yes__ No__; Remote: Yes__ No__
Grocery store: Yes:__ No:__; Pharmacy: Yes__ No__; Health Care Facility:
Yes:__ No:__; Transporation: Yes:__ No:__; Telephone (for police, fire,
ambulance): Yes:__ No:__; If any difficulties, note referral here:
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7. Can patient move easily (turning, walking)? Yes__ No__
12. Medications (over-the-counter and prescription) 8. Upon admission, was patient dressed appropriately for the weather?
Yes__ No__ Describe:
Name Dosage Times/Da Reason Taken as Ordered
y For breastfeeding mothers only:
Yes__ No__
9. Breast exam: Normal__ Abnormal__
10. If mother is breastfeeding, have infant weighed. Is infant’s weight within
13. Have you followed the routine prescribed for you? normal limits? Yes__ No__
Yes__ No__ Why not?
14. Did you think this prescribed routine was best for you? SUBJECTIVE:
Yes__ No__ What would be better? 1. Any weight gain in the last 6 months? No__ Yes__ Amount:
15. Have you had any accidents/injuries/falls in the past year? 2. Any weight loss in the last 6 months? No__ Yes__ Amount:____________
No__ Yes__ Describe: 3. How would you describe your appetite? Good__ Fair__ Poor__
16. Have you had any problems with cuts healing? 4. Do you have any food intolerance? No__ Yes__ Describe:
No__ Yes__ Describe: 5. Do you have any dietary restrictions? (Check for those that are a part of a
17. Do you exercise on a regular basis? prescribed regimen as well as those that patient restricts voluntarily, for
No__ Yes__ Type & Frequency: example, to prevent flatus) No__ Yes__ Describe:
18. Describe the place you are currently living in______________ 6. Describe an average day’s food intake for you (meals and snacks):
19. Does he/she have any pets? If so, what kind? 7. Describe an average day’s fluid intake for you.
20. What does the person do to improve or maintain his/her health?__________ 8. Food preparation ______
21. Have you experienced any ringing in the ears: Right ear: Yes__ No___ Left 9. Describe food likes and dislikes.
ear: Yes__ No__ 10. Would you like to: Gain weight?__ Lose weight?__ Niether__
22. Have you experienced any vertigo: Yes__ No__ How often and when? 11. Any problems with:
23. Do you regularly use seat belts? Yes__ No__ a. Nausea: No__ Yes__ Describe:
24. For infants and children: Are car seats used regularly? Yes__ No__ b. Vomiting: No__ Yes__ Describe:
25. Do you have any suggestions or requests for improving your health? c. Swallowing: No__ Yes__ Describe:
Yes__ No__ Describe: d. Chewing: No__ Yes__ Describe:
26. What are THE PRACTICED traditional concepts of health and illness?Beliefs e. Indigestion: No__ Yes__ Describe:
and practices? ___________________________ 12. Would you describe your usual lifestyle as: Active__ Sedate__
27. Do you do (breast/testicular) self-examination? No__ Yes__
For breastfeeding mothers only:
13. Do you have any concerns about breast feeding? No__ Yes__ Describe:
NUTRITIONAL-METABOLIC PATTERN ___________________________________________________
14. Are you having any problems with breastfeeding? No__ Yes__ Describe:
OBJECTIVE MEALS Date & Day Date & Day Date & Day
1. Skin examination
a. Warm__ Cool__ Moist__ Dry__ Breakfast
b. Lesions: No__ Yes__ Describe: (time)
c. Rash: No__ Yes__ Describe: Snacks (if - amount per - amount per - amount per serving
d. Turgor: Firm__ Supple__ Dehydrated__ Fragile__ any) serving serving
e. Color: Pale__ Pink__ Dusky__ Cyanotic__ Jaundiced__ Mottled__ Lunch (time)
Other________________________________________________ Snacks (if - amount per - amount per - amount per serving
any) serving serving
2. Mucous Membranes Dinner (time)
a. Mouth
i. Moist__ Dry__ Snacks (if - amount per - amount per - amount per serving
ii. Lesions: No__ Yes__ Describe: any) serving serving
iii. Color: Pale__ Pink__ Total Fluid ___mL ___mL ___mL
iv. Teeth: Normal__ Abnormal__ Intake
v. Dentures: No__ Yes__ Upper__ Lower__ Partial__ (problems?- ___________________________________________________
cause____________)
vi. Gums: Normal__ Abnormal__
vii. Tongue: Normal__ Abnormal__
ELIMINATION PATTERN
b. Eyes
i. Moist__ Dry__ OBJECTIVE
ii. Color of conjunctiva: Pale__ Pink__ Jaundiced__ 1. Auscultate abdomen:
iii. Lesions: No__ Yes__ a. Bowel sounds: Normal__ Increased__ Decreased__ Absent__
Male
1. History of prostate problems? No__ Yes__ Describe:
2. History of penile discharge, bleeding, lesions: No__ Yes__ Describe:
3. Date of last prostate exam:
4. History of sexually transmitted diseases: No__ Yes__ Describe:
5.
Both
1. Are you experiencing any problems in sexual functioning? No__ Yes__
Describe:_____
2. Are you satisfied with your sexual relationship? Yes__ No__
Describe:___________________________________________________
3. Do you believe this admission will have any impact on sexual functioning?
No__ Yes__ Describe:
OBJECTIVE
1. Observe behavior: Are there any overt signs of stress (crying, wringing of
hands, clenched fists, etc)? Describe: ____________________________
SUBJECTIVE
1. Have you experienced any stressful or traumatic events in the past year in
addition to this admission? No__ Yes__ Describe:______
2. How would you rate your usual handling of stress? Good__ Average__ Poor__
3. What is the primary way you deal with stress or problems?
4. Have you or your family used any support or counseling groups in the past
year? No__ Yes__ Group name:
Was the support group helpful? Yes__ No__ Additional comments: What do
you believe is the primary reason behind a need for this admission?
5. How soon, after first noting the symptoms, did you seek health care
assistance?
6. Are you satisfied with the care you have been receiving at home? No__ Yes __
Comments:
7. Ask primary caregiver: What is your understanding of the care that will be
needed when the patient goes home?
VALUE-BELIEF PATTERN
OBJECTIVE
1. Observe behavior. Is the patient exhibiting any signs of alterations in mood
(anger, crying, withdrawal, etc.)? Describe: __
SUBJECTIVE
1. Satisfied with the way your life has been developing? Yes__ No__ Comments:
2. Will this admission interfere with your plans for the future? No__ Yes__ How?
3. Religion: Protestant__ Catholic__ Jewish__ Muslim__ Buddhist__ None__
Other:
4. Will this admission interfere with your spiritual or religious practices? No__
Yes__ How?
5. Any religious restrictions to care (diet, blood transfusions)? No__ Yes__
Describe:
6. Would you like to have your (pastor/priest/rabbi/hospital chaplain) contacted to
visit you? No__ Yes__ Who?
7. Have your religious beliefs helped you to deal with problems in the past?
No__ Yes__ How?_______________________________
8. How important is health to you?
9. Any spiritual or religious practices important to you? Relevance to
health?
10. Is religion important in your life? Does this help when difficulties arise?
GENERAL
1. Is there any information we need to have that I have not covered in this
interview? No__ Yes__ Comments?
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