Health History Assessment Question Guide Gordons Functional Health Pattern Date Performed: Client in Context: Name: Age:

Civil Status: Place of Residence: Admitting Complaints: No. of prior admissions in CVGH: Source of Hx/Data: Name: Reasons for seeking health care/CC: Chief complaint? Feelings about seeking health care? History of Present illness: Can you narrate to me exactly what happened prior to your admission? When did it start? What symptoms did you observe? For how long? Precipitating factors? What did you do or what were you doing when it happened? Relieving factors? What activity relieves problem? Did you self medicate? What were these drugs? Any relief? Did you practice herbal medication or folk medication? If yes, what were these? Who advised you on them? Any consultations done? Who was the doctor? Did the doctor prescribe any medications? What were these? Compliance? Relief noted? Diagnosis made by doctor PTA? Any laboratory exams done before admission? Results? Who recommended hospitalization? What prompted you to seek medical attention? Character? Onset? Better, worse? Duration? Severity? Aggravating factors? Other symptoms with it? Able to do ADL's? Ward & Room/Bed#: Case No.:

Sex: Religion: Date of Admission: How patient was admitted: Date complaints were noted: Doctor:

Age:

Relationship:

Location? Relieving factors?

Past Health History: Hypertensive? If yes: for how many years now? When diagnosed? By whom? Normal average BP? Highest BP? Any maintenance medication? What are these? Relief noted? Compliance? Diabetic? If yes: for how many years now? When diagnosed? By whom? last known blood sugar? Highest? Average? Maintenance medication? What are these? Relief noted? Compliance? smoker? If yes: how many sticks per day? For how long now? When and why do you smoke? How often do you smoke? Alcoholic? If yes: how many bottles of beer a day? How long have you been drinking? How often do you drink? When do you usually drink? Why do you drink? Food and drug allergies? Heredo-familial diseases? On maternal side? On paternal side? Problems at birth? Childhood illnesses? Accidents/Injuries? Previous hospitalization: How many times have you been hospitalized? For each hospitalization: When were you hospitalized? Admitting complaints? Who was your doctor? Rehabilitation done after? Compliance to prescribed meds? Environmental History: Where do you live? How long have you lived there? How far from nearest health center? Urban/ suburban/ rural? Is house and lot owned? How many people sleep in every room? Pets? How many? Elaborate Accessible to basic services?

Can you recall the exact date or year? Did condition improve upon discharge? How long did you stay in the hospital? Procedures performed? Actions taken? How was the final diagnosis? Surgery done? Medications given during hospitalization? Take home medications prescribed? Alteration in ADLs / body function after? Where hospitalized?

How many bedrooms? How far is it from church? How far from brgy hall? Water source? Supplied by? How many people live in house? How many windows? how accessible to market? Peace and order situation in area?

How many stories? How far from main road? Describe neighborhood? Congested? Electricity? Supplied by? Adequate sleeping quarters? Space around house? Or firewall? How accessible to transportation?

Gordons functional health pattern: HEALTH PERCEPTION HEALTH MANAGEMENT How do you look at life and your health? Good? Bad? How would you rate your health? Why? Do you have any medical check ups? Who do you usually go to for primary health care? How often or when do you usually see a doctor? Do you see quack doctors or practice folk medicine? Do you practice self medication? Why or why not? Do you perform BSE or TSE? Are you aware of your condition? How much do you know about your illness? Elaborate What do you think caused it? Are you fully immunized? When prescribed medicines, do you follow the prescription? Do you take any measures to safeguard you health? What are these? Has your sickness and hospitalization changed the way you view your health? How? NUTRITION METABOLIC PATTERN Height: Weight: IBW: Kind of diet in hospital: Banana per meal included? If with NGT: Kind of diet: calories per day: cc per day: Feedings per day: cc per feeding: grams fat: Grams CHO: grams CHON: How often do you eat in a day? What do you usually eat during your meals? Breakfast? Lunch? Dinner? When do you eat breakfast? Lunch? Dinner? With whom do you usually eat? Where? Any favorite foods? If so, what are these? Do you have any problems in eating like difficulty in chewing or swallowing? Do you have regular dental exams? How often or when do you see a dentist? Have you ever consulted one? Do you have any dentures? How about fillings? Any missing teeth? Do you take supplements? What are these if any? Do you take in fruits daily? What are these? Has your diet changed with your sickness and subsequent hospitalization? How? How much liquids do you usually take in per day? Any weight loss noted? ELIMINATION PATTERN How often do you eliminate your bowel? What are your bowel habits? When do you usually move your bowel? Describe your stools color? Form? Do you use laxatives? Any difficulty eliminating your bowel? Do you experience constipation? If so, what do you do to help remedy the problem? How often do you void? How many times do you void per day? Describe your urine color? Clear? How strong is your urine flow? How much do you usually void per setting? Per day? Any problems with voiding? Pain? Blood? Has your sickness or hospitalization changed your elimination pattern? How? ACTIVITY EXERCISE PATTERN What is your occupation in life? Describe your job. Stressful? Physical? What do you do? What time do you usually report for work? How about going home? When do you usually wake up? What do you do upon waking? What do you usually do after breakfast? Lunch? Dinner? What do you usually do in the morning? Afternoon? Evening? Do you have siesta time after meals? Do you take naps in the morning? Afternoon? What do you usually do before going to bed? Do you practice regular exercise? If so, how often? Why or why not? What do you do for recreation? Who do you usually spend recreational time with? Has your sickness changed your activity pattern? How? SLEEP AND REST PATTERN When do you usually sleep? What time do you usually wake up? Do you use any sleeping aids? What are these? Do you take drugs or sedatives to facilitate sleep? How many pillows do you use? Do you have any problems sleeping? What do you usually do or take in if you have a hard time sleeping at night?

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After onset

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In hospital

Is your sleep restful? Do you feel refreshed upon waking up? Has your current condition affected your sleep and rest? How? Have you been getting enough rest lately? COGNITIVE PERCEPTUIAL PATTERN Is patient oriented to time, place and people? Patients sensory status? Is patient able to recall past events? Does patient know his name or how old he is? Is patient able to recall the events that happened yesterday? Has patients current condition markedly affected his cognition and perception? How? SELF PERCEPTION AND SELF CONCEPT PATTERN How do you see yourself? Is it in a positive or negative way? What can you say about yourself? How about your accomplishments in life? What can you say about your life? How have you lived it? Are you satisfied with how things have gone for you? Are you happy with yourself and what you have done with your life? Any problems? Worries? Or concerns as of now? Fears about your illness? Do you believe that you will be cured? Has your current condition affected your perception or the way you view yourself? How ROLE RELATIONSHIP PATTERN What place do you occupy in your family? Are you the eldest? Youngest? How many siblings do you have? How good is your relationship with them? How many children do you have? How good is your relationship with them? How long have you been married to your wife? How is your relationship with your wife? Any problems? Has your marriage been satisfying and fulfilling for the both of you? What is your role in your current family today? Are you satisfied or happy with it? Do you have a lot of friends? Acquaintances? Relatives? How is your relationship with these people? Has your current condition affected your relationships or the way you interact with other people? How? What have you done to adjust? SEXUALITY REPRODUCTIVE PATTERN When did your puberty start? What did you notice? When were you circumcised? When was your first sexual contact? With whom? How many partners have you had since then? Are you choosy when it comes to partners? (if multiple) Any history of STD? Any history of contraceptive use? Are you currently sexually active? How often do you usually do the act? Has your illness affected your sexual activities? How? COPING STRESS TOLERANCE PATTERN How would you view or define stress? Do you believe you are stressed right now? Why or why not? Who makes most of the major decisions in your family? Do you consult with other members before making such decisions? Who runs the everyday activities of the house? What can you say about your current illness? What is your outlook on life? Good or bad? Do you currently have any major family problems? What are these? What do you do when personal problems arise? With whom do you share your problems with? What do you do when conflicts with your relatives, friends, or neighbors happen? How do you usually solve your problems? What do you usually do to relieve stress? Has your current condition stressed you or in any way affected you in the way you cope with and manage your problems? In what way? VALUE BELIEF PATTERN What is your religion? Can you tell us about it? Your practices, beliefs and rituals? (if not catholic) Do you have the same religion as your parents and with the rest of the family? Do you believe in God? What is your concept of him? How often do you attend religious services? With whom? From a religious point of view, how would you describe yourself? Do you pray? How often do you do so? Do you ask help from a higher being in times of need and crisis? Before onset After onset In hospital

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Has your current condition affected you in the way you practice your faith? GENOGRAM: ECOMAP:

PHYSICAL EXAMINATION: General appearance: Seen patient (sitting / lying / ________________) on (bed / chair / ___________), (awake / asleep), (responsive / nonresponsive), (coherent / incoherent) with NGT in place with oxygen inhalation flowing well via (nasal cannula / face mask / ET tube) regulated at 2 L/min., with ISA, with IVF of _________ (1 liter / 1 pint) regulated at ________ (gtts / ugtts)/min infusing well at (left / right) (arm / leg), with colostomy bag in place at (right / left) abdomen, with hemovac in place and draining well at __________, with FBC CDU draining well, and with the ff V/S: BP _______ mmHG, PR ________bpm, RR _________cpm, T _________C/ (orem / axilla / rectum); O2 sat:_________; height _______, weight _______, IBW:_________ BMI & interpretation:___________ Attachments on px: Breast : Uterus: Bladder: Bowel: Lochia: Episiotomy: Homans sign: Emotional Status: SKIN Jaundice Lesions POSITIVE Redness Tenderness Edema Distribution/Config Ecchymosis Discharges Approximation Evenly colored skin tone Good warm Slightly moist Smooth and even Thin c calluses noted on plantar surface Not noted NEGATIVE

Color Turgor Temp Moisture Texture Thickness Edema HEAD AND HAIR Dandruff Lice Tenderness Distribution Color of hair Normocephalic Condition Configuration and symmetry consistency Facial symmetry Involuntary mov'ts TMJ

Poor / senile

Rebounds, does not remain indented

Equally

Not equally

Clean, dry Symmetric, round, erect Hard, smooth, s lesions or lumps symmetric Still, upright, no abn facial mov'ts noted

Oiliness, lesions

No swelling, tenderness, crepitation c mov't, closes and opens fully, 1-2cm in each direction

NAILS Color shape condition

Transparent, pinkish 160 angle bet. Nail base & skin, no clubbing Clean, well-trimmed, smooth, firm, hard, nailplate firmly attached to nailbed

EYES PERRLA Discharges eyeballs eyelids

Lacrimal apparatus Cornea and lens

Symmetrically aligned in sockets s protruding/sinking Lashes short, evenly spaced, curled outward, lower lid at bottom edge, upper lid covers 2mm or iris, lid margins pink and moist s swelling/lesions, close easily Puncta visible s swelling/redness, no tenderness/drainage, minimal lacrimation Transparent, moist s opacities, lenses are clear

iris Color of sclerae Bulbar conjunctiva Palpebral conjunctiva Eyebrows EXTRAOCULAR MUSCLE FX Corneal light reflex test Cover test Cardinal gaze

Round, uniform color White Clear, moist, smooth, tiny vessels visible Pink, moist s swelling, lesions, foreign bodies, trauma/ abn discharges Equal hair distribution

Red Pale Unequal

Reflexions of light noted at same location on both eyes Uncovered eye remains fixed, covered eye does not move as cover is removed Both move in smooth coordinated manner in all 6 directions

VISION Color vision Visual acuity: distant Visual acuity: near Peripheral vision (Confrontation test)

Able to identify primary colors around the room 20/20 OU s hesitation, frowning or squinting Reads print at 14 in s difficulty Sees examiner finger at same time examiner sees it/visual fields full by confrontation

EARS Cerumen Tenderness (auricle, mastoid process, canal) Discharges Symmetrical Can hear whispered voices Auricle position

Equal in size bilaterally about 5 cm Outer pinna in line with inner canthus, 10 degree angle of vertical position, free earlobes (attached soldered) Smooth s lesions, lumps or nodules, color consistent c face Canal walls pink, smooth s nodules, tympanic membrane shiny, pearly gray

External ear External canal

HEARING Whisper test Watch tick test Weber test Rinne test NOSE External portion patency Internal portion

Repeats 2-syllable word at 3-ft distance Reports hearing watch tick within 5 in from ear Vibrations heard equally well in both ears, no lateralization of sound AC>BC

Percussion, palpation of sinuses Flaring Discharges Transillumination Septum at midline MOUTH Lips Gag reflex Teeth and gums

Color consistent c rest o e face, smooth, symmetric, no tenderness Able to sniff, blow through each nostril while other is occluded Nasal muscosa is dark pink, moist, free of exudate, septum at midline, free of ulcers or perforation non-tender

Clear frontal and maxillary sinuses

Oral mucosa Tongue

Uvula

Pink, smooth, moist, s lesions or swelling intact 32 white-yellowish teeth, no decayed areas, no dental appliance, pink gums, moist, firm, tight margins to the tooth, no lesions, redness, swelling noted Pink, smooth, moist and s lesions, stenson's ducts visible s redness, swelling or pain Moist, pinkish, at midline, s lesions, nodules or fasciculations, papillae present on dorsal surface, ventral surface smooth & shiny, pink, small visible veins present, frenulum in midline c visible wharton's ducts on each side Pink, moist, hangs freely in midline s redness

pale

Palate (hard, soft) Breath odor Tonsils Oropharynx/posterior pharyngeal wall NECK Symmetry

or exudate Whitish hard palate c firm transverse rugae, smooth, pink, moist soft palate, no lesions No unusual or foul odor noted 1+, pink, symmetric s exudate, swelling, lesions Pink, s exudate or lesions

ROM Trachea Thyroid gland

Lymph nodes BREAST Shape Symmetry Nipples

Symmetric c head centered, thyroid cartilage, cricoid cartilage, thryroid gland move upward symmetrically when swallowing Full, smooth, sontrolled Midline Landmarks at midline, palpable when swallowing, smooth, firm, non-tender, s nodules/bruits Palpable

Not palpable

Round, pendulous R slightly larger than L Everted bilaterally c light brown areola, montgomery tubercules present, no dimpling, retraction, lesions/inflammation No masses/tenderness noted Minimal amount Nonpalpable

Masses Discharges Lymph nodes THORAX AND LUNGS Adventitious breath sounds Configuration

Retractions and bulging Depth, rhythm and quality o respiration Crepitus Fremitus Percussion tone Diaphragmatic excursions Breath sounds

Voice sounds

Tenderness Chest expansion HEART Distinct s1 and s2 Heaves (visible pulsations) Apical impulse Abnormal pulsations (thrills, etc) Rate and rhythm of apical pulse Pulse deficit Extra heart sounds Murmurs Chest pain Normal rate and rhythm NECK VESSELS Jugular vein distention, hepatojugular reflux Jugular venous pressure Bruits (carotid arteries) PERIPHERAL VASCULATURE arm/leg edema

Not noted Scapulae symmetric, nonprotruding, AP less than T, sternum straight at midline, ribs slope downward c symmetric ICS, costal angle c/in 90 deg Not noted Regular, relaxed, effortless, quiet s use of accessory muscles Not noted Symmetric, easily identified in upper regions of lungs, decreases in intensity at bases Resonant on all lung fields 4cm, equal bilaterally Bronchial sounds noted over trachea, bronchovesicular over major bronchi & vesicular over peripheral lung fields Broncophony soft, muffled, indistinct egophony soft, muffled, letter E distinguishable whispered pectoriloquy very faint, muffled nontender Equal, 5 cm apart anteriorly and posteriorly

Unequal

S1 distinct, heard best at apex s2 distinct, heard best at base Not noted 5 ICS at left MCL Not noted 70 bpm, regular 0 Not noted
th

Not noted when ct is sitting upright, no hepato-jugular reflux 1 cm above sternal angle c head of bed elevated to 30 deg Not noted

obstructed/too narrow

Bilaterally symmetric, no edema (pitting/non-

pitting) Nail beds, capillary refill time Allen test Varicosities Homan's sign Rate and amplitude of peripheral pulses ABDOMEN Gross appearance, contour Bowel sounds Symmetry Striae Umbilicus Aortic pulsations Peristaltic waves Bowel sounds Vascular sounds, friction rubs Percussion tone Liver span Liver palpation Spleen All pinkish, <2 sec R ulnar and radial arteries patent L ulnar and radial arteries patent Not noted R , L negative

Masses palpated Kidneys Urinary bladder Shifting dullness Fluid wave test Rebound tenderness Psoas sign Obturator sign Mass present Abdominal girth Abdominal pain EXTREMITIES Full ROM Peripheral pulses Strength Edema CRT GENITO URINARY Grossly Pain in urination Lesions Discharges RECTUM: Perianal area: Anus: MALE GENITALIA & PROSTATE: Penis Base & Pubic Hair: Foreskin and glans: Scrotum Size, shape and position: Testicles & nearby structures: Inguinal area Hernias: Prostate: FEMALE GENITALIA: External genitalia Mons pubis: Labia majora and perineum: Urethra: Internal genitals Vaginal mucosa: BACK AND EXTREMITIES: Gait: ROM: (full or limited)

Flabby, thin or muscular/flat, round, globular, scaphoid Normal, hyperactive, or hypoactive Symmetric s bulges or lumps, no bulges noted when ct raises head Not noted Midline, recessed, s bulging Slight pulsations noted Not seen Soft gurgles, clicks heard at 15 per min No bruits, venous hums, or friction rubs Generalized tympany over all quadrants MCL 8 cm; MSL 6 cm Not palpable, no tenderness Percussion discloses a dull oval area approx. th 7cm wide near left 10 rib posterior to MAL; not palpable, no tenderness None Nontender at blunt percussion of CVA, not palpable Flat percussion tone on empty bladder, not palpable Constant borders between tympany and dullness throughout position changes No fluid wave transmitted Not noted Not noted negative Yes No cm. COLDSPA

Strong Strong < 2 sec

Weak Weak > 2 sec

Male

Female

Sacrococcygeal area: Rectum:

Shaft: Urethral opening and discharge: Scrotal skin: Masses: Lymph nodes:

Inguinal lymph nodes: Labia minora, clitoris, vaginal opening: Bartholin's glands: Cervix:

Posture/Stature:

Symmetry:

spine: cervical : upper extremities: shoulders: lower extremities: hips: crepitus: fasciculations: bony deformities: muscle strength: special tests: phalen's test: lasegue test: ballottement knee test

thoracic and lumbar: elbows: knees:

arms: ankles and feet:

wrist:

hands and fingers:

tinel's test: bulge knee test: mcmurray's test:

NEUROLOGIC ASSESSMENT: Mental status/Cerebral Fx: LOC: Dress, hygiene and grooming: Speech: Orientation: Person: Attention: Fund of Info: Similarities: Visual Perceptual & Constructional Ability: Motor/Cerebellar Fx: Rapid alternating mov'ts: Finger-nose: Button-unbutton: Romberg test: Sensory Fx: Light touch sensation: Vibratory: stereognosis: kinesthesia: CN testing: 1 OLFACTORY (S) 2 OPTIC (S) 3,4,6 OCULOMOTOR, TROCHLEAR, ABDUCENS (M) 5 TRIGEMINAL (B)

GCS: Facial expressions: Vocabulary: Place: Memory: Remote: Abstract reasoning: Judgment:

Mood/Affect: Thought processes: Time: Recent:

Finger thumb test: Heel to shin: Tandem walk: Involuntary mov'ts:

Discrimination bet. sharp and dull: 2-pt discrimination: graphesthesia:

correctly identifies scent 20/20 OU, reads print 14 in away, full peripheral vision full extraocular mov't, PERRLA

corneal reflex present, identifies light, sharp, dull touch to forehead, cheek and chin, clenches teeth correctly identifies taste of sugar and salt, able to smile, frown, wrinkle forehead, show teeth, puff out cheeks, purse lips, raise eyebrows, close eyes against resistance whispered words heard within 3 ft bilaterally, vibration heard equally well in both ears, AC>BC, maintains balance even when eyes are closed Uvula and palate rise symmetrically when client says ah, gag reflex present, swallows s difficulty

7 FACIAL (B)

8 VESTIBULOCOCHLEAR (S)

9,10 GLOSSOPHARYNGEAL, VAGUS (B)

11 SPINAL ACCESSORY (M) 12 HYPOGLOSSAL (M) DEEP TENDON REFLEXES:

Equal shoulder shrug against resistance, turns head in both directions against resistance Protrudes tongue in midline, able to push tongue blade to R and L s difficulty

SUPERFICIAL REFLEXES: abdominal: PATHOLOGIC REFLEXES: brudzinki's sign:

cremasteric: Kernig's sign:

plantar: