Health History Assessment Question Guide

Gordon’s Functional Health Pattern

Date Performed: Ward & Room/Bed#: Case No.:

Client in Context:
Name: Sex:
Age: Religion:
Civil Status: Date of Admission:
Place of Residence: How patient was admitted:
Admitting Complaints: Date complaints were noted:
No. of prior admissions in CVGH: Doctor:

Source of Hx/Data:
Name: Age: Relationship:

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? Location?
Duration? Severity? Aggravating factors? Relieving factors?
Other symptoms with it? Able to do ADL's?

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? Can you recall the exact date or year? Did condition improve upon discharge?
Admitting complaints? How long did you stay in the hospital? Procedures performed? Actions taken?
Who was your doctor? How was the final diagnosis? Surgery done?
Rehabilitation done after? Medications given during hospitalization? Take home medications prescribed?
Compliance to prescribed meds? Alteration in ADL’s / body function after? Where hospitalized?

Environmental History:
Where do you live? How many bedrooms? How many stories?
How long have you lived there? How far is it from church? How far from main road?
How far from nearest health center? How far from brgy hall? Describe neighborhood? Congested?
Urban/ suburban/ rural? Water source? Supplied by? Electricity? Supplied by?
Is house and lot owned? How many people live in house? Adequate sleeping quarters?
How many people sleep in every room? How many windows? Space around house? Or firewall?
Pets? How many? Elaborate how accessible to market? How accessible to transportation?
Accessible to basic services? Peace and order situation in area?
Gordon’s functional health pattern:
HEALTH PERCEPTION HEALTH MANAGEMENT Before onset After onset In hospital
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 Before onset After onset In hospital

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 Before onset After onset In hospital

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 Before onset After onset In hospital

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 Before onset After onset In hospital

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?
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 Before onset After onset In hospital

Is patient oriented to time, place and people?
Patient’s 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 patient’s current condition markedly affected his cognition and perception? How?

SELF PERCEPTION AND SELF CONCEPT PATTERN Before onset After onset In hospital
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 Before onset After onset In hospital

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 Before onset After onset In hospital

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 Before onset After onset In hospital

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 Before onset After onset In hospital

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?
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: Homan’s sign: Emotional Status:

SKIN POSITIVE NEGATIVE

Jaundice
Lesions Redness Tenderness Not noted
Edema Distribution/Config
Ecchymosis
Discharges
Approximation
Color Evenly colored skin tone
Turgor Good Poor / senile
Temp warm
Moisture Slightly moist
Texture Smooth and even
Thickness Thin c calluses noted on plantar surface
Edema Rebounds, does not remain indented

HEAD AND HAIR

Dandruff
Lice
Tenderness
Distribution Equally Not equally
Color of hair
Normocephalic
Condition Clean, dry Oiliness, lesions
Configuration and symmetry Symmetric, round, erect
consistency Hard, smooth, s lesions or lumps
Facial symmetry symmetric
Involuntary mov'ts Still, upright, no abn facial mov'ts noted
TMJ No swelling, tenderness, crepitation c mov't,
closes and opens fully, 1-2cm in each
direction

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

EYES
PERRLA
Discharges
eyeballs Symmetrically aligned in sockets s
protruding/sinking
eyelids 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
Lacrimal apparatus Puncta visible s swelling/redness, no
tenderness/drainage, minimal lacrimation
Cornea and lens Transparent, moist s opacities, lenses are
clear
iris Round, uniform color
Color of sclerae White Red
Bulbar conjunctiva Clear, moist, smooth, tiny vessels visible
Palpebral conjunctiva Pink, moist s swelling, lesions, foreign Pale
bodies, trauma/ abn discharges
Eyebrows Equal hair distribution Unequal

EXTRAOCULAR MUSCLE FX
Corneal light reflex test Reflexions of light noted at same location on
both eyes
Cover test Uncovered eye remains fixed, covered eye
does not move as cover is removed
Cardinal gaze Both move in smooth coordinated manner in
all 6 directions

VISION
Color vision Able to identify primary colors around the
room
Visual acuity: distant 20/20 OU s hesitation, frowning or squinting
Visual acuity: near Reads print at 14 in s difficulty
Peripheral vision (Confrontation test) Sees examiner finger at same time examiner
sees it/visual fields full by confrontation

EARS
Cerumen
Tenderness (auricle, mastoid process, canal)
Discharges
Symmetrical Equal in size bilaterally about 5 cm
Can hear whispered voices
Auricle position Outer pinna in line with inner canthus, 10
degree angle of vertical position, free
earlobes (attached soldered)
External ear Smooth s lesions, lumps or nodules, color
consistent c face
External canal Canal walls pink, smooth s nodules,
tympanic membrane shiny, pearly gray

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

NOSE
External portion Color consistent c rest o e face, smooth,
symmetric, no tenderness
patency Able to sniff, blow through each nostril while
other is occluded
Internal portion Nasal muscosa is dark pink, moist, free of
exudate, septum at midline, free of ulcers or
perforation
Percussion, palpation of sinuses non-tender
Flaring
Discharges
Transillumination Clear frontal and maxillary sinuses
Septum at midline

MOUTH
Lips Pink, smooth, moist, s lesions or swelling
Gag reflex intact
Teeth and gums 32 white-yellowish teeth, no decayed areas,
no dental appliance, pink gums, moist, firm,
tight margins to the tooth, no lesions,
redness, swelling noted
Oral mucosa Pink, smooth, moist and s lesions, stenson's pale
ducts visible s redness, swelling or pain
Tongue 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
Uvula Pink, moist, hangs freely in midline s redness
or exudate
Palate (hard, soft) Whitish hard palate c firm transverse rugae,
smooth, pink, moist soft palate, no lesions
Breath odor No unusual or foul odor noted
Tonsils 1+, pink, symmetric s exudate, swelling,
lesions
Oropharynx/posterior pharyngeal wall Pink, s exudate or lesions

NECK
Symmetry Symmetric c head centered, thyroid cartilage,
cricoid cartilage, thryroid gland move upward
symmetrically when swallowing
ROM Full, smooth, sontrolled
Trachea Midline
Thyroid gland Landmarks at midline, palpable when
swallowing, smooth, firm, non-tender, s
nodules/bruits
Lymph nodes Palpable Not palpable

BREAST
Shape Round, pendulous
Symmetry R slightly larger than L
Nipples Everted bilaterally c light brown areola,
montgomery tubercules present, no dimpling,
retraction, lesions/inflammation
Masses No masses/tenderness noted
Discharges Minimal amount
Lymph nodes Nonpalpable

THORAX AND LUNGS

Adventitious breath sounds Not noted
Configuration Scapulae symmetric, nonprotruding, AP less
than T, sternum straight at midline, ribs slope
downward c symmetric ICS, costal angle c/in
90 deg
Retractions and bulging Not noted
Depth, rhythm and quality o respiration Regular, relaxed, effortless, quiet s use of
accessory muscles
Crepitus Not noted
Fremitus Symmetric, easily identified in upper regions
of lungs, decreases in intensity at bases
Percussion tone Resonant on all lung fields
Diaphragmatic excursions 4cm, equal bilaterally
Breath sounds Bronchial sounds noted over trachea,
bronchovesicular over major bronchi &
vesicular over peripheral lung fields
Voice sounds Broncophony – soft, muffled, indistinct
egophony – soft, muffled, letter E
distinguishable
whispered pectoriloquy – very faint, muffled
Tenderness nontender
Chest expansion Equal, 5 cm apart anteriorly and posteriorly Unequal

HEART
Distinct s1 and s2 S1 distinct, heard best at apex
s2 distinct, heard best at base
Heaves (visible pulsations) Not noted
Apical impulse 5th ICS at left MCL
Abnormal pulsations (thrills, etc) Not noted
Rate and rhythm of apical pulse 70 bpm, regular
Pulse deficit 0
Extra heart sounds Not noted
Murmurs
Chest pain
Normal rate and rhythm

NECK VESSELS
Jugular vein distention, hepatojugular reflux Not noted when ct is sitting upright, no
hepato-jugular reflux
Jugular venous pressure 1 cm above sternal angle c head of bed
elevated to 30 deg
Bruits (carotid arteries) Not noted obstructed/too narrow

PERIPHERAL VASCULATURE
arm/leg edema Bilaterally symmetric, no edema (pitting/non-
pitting)
Nail beds, capillary refill time All pinkish, <2 sec
Allen test R ulnar and radial arteries patent
L ulnar and radial arteries patent
Varicosities Not noted
Homan's sign R , L negative
Rate and amplitude of peripheral pulses

ABDOMEN
Gross appearance, contour Flabby, thin or muscular/flat, round, globular, scaphoid
Bowel sounds Normal, hyperactive, or hypoactive
Symmetry Symmetric s bulges or lumps, no bulges
noted when ct raises head
Striae Not noted
Umbilicus Midline, recessed, s bulging
Aortic pulsations Slight pulsations noted
Peristaltic waves Not seen
Bowel sounds Soft gurgles, clicks heard at 15 per min
Vascular sounds, friction rubs No bruits, venous hums, or friction rubs
Percussion tone Generalized tympany over all quadrants
Liver span MCL – 8 cm; MSL – 6 cm
Liver palpation Not palpable, no tenderness
Spleen Percussion discloses a dull oval area approx.
7cm wide near left 10th rib posterior to MAL;
not palpable, no tenderness
Masses palpated None
Kidneys Nontender at blunt percussion of CVA, not
palpable
Urinary bladder Flat percussion tone on empty bladder, not
palpable
Shifting dullness Constant borders between tympany and
dullness throughout position changes
Fluid wave test No fluid wave transmitted
Rebound tenderness Not noted
Psoas sign Not noted
Obturator sign negative
Mass present Yes No
Abdominal girth cm.
Abdominal pain COLDSPA

EXTREMITIES
Full ROM
Peripheral pulses Strong Weak
Strength Strong Weak
Edema
CRT < 2 sec > 2 sec

GENITO URINARY
Grossly Male Female
Pain in urination
Lesions
Discharges

RECTUM:
Perianal area: Sacrococcygeal area:
Anus: Rectum:

MALE GENITALIA & PROSTATE:

Penis – Base & Pubic Hair: Shaft:
Foreskin and glans: Urethral opening and discharge:
Scrotum – Size, shape and position: Scrotal skin:
Testicles & nearby structures: Masses:
Inguinal area – Hernias: Lymph nodes:
Prostate:

FEMALE GENITALIA:
External genitalia – Mons pubis: Inguinal lymph nodes:
Labia majora and perineum: Labia minora, clitoris, vaginal opening:
Urethra: Bartholin's glands:
Internal genitals – Vaginal mucosa: Cervix:

BACK AND EXTREMITIES:

Gait: Posture/Stature: Symmetry:

ROM: (full or limited)

spine: cervical : thoracic and lumbar:
upper extremities: shoulders: elbows: arms: wrist: hands and fingers:
lower extremities: hips: knees: ankles and feet:
crepitus:
fasciculations:
bony deformities:
muscle strength:
special tests: phalen's test: tinel's test:
lasegue test: “bulge knee” test:
“ballottement” knee test mcmurray's test:

NEUROLOGIC ASSESSMENT:
Mental status/Cerebral Fx:
LOC: GCS: Mood/Affect:
Dress, hygiene and grooming: Facial expressions:
Speech: Vocabulary: Thought processes:
Orientation: Person: Place: Time:
Attention: Memory: Remote: Recent:
Fund of Info: Abstract reasoning:
Similarities: Judgment:

Visual Perceptual & Constructional Ability:

Motor/Cerebellar Fx:
Rapid alternating mov'ts: Finger thumb test:
Finger-nose: Heel to shin:
Button-unbutton: Tandem walk:
Romberg test: Involuntary mov'ts:

Sensory Fx:
Light touch sensation: Discrimination bet. sharp and dull:
Vibratory: 2-pt discrimination:
 stereognosis: graphesthesia:
kinesthesia:

CN testing:

1 – OLFACTORY (S) – correctly identifies scent

2 – OPTIC (S) – 20/20 OU, reads print 14 in away, full peripheral vision

3,4,6 – OCULOMOTOR, TROCHLEAR, ABDUCENS (M) – full extraocular mov't, PERRLA

5 – TRIGEMINAL (B) – corneal reflex present, identifies light, sharp, dull touch to forehead, cheek and chin,
clenches teeth

7 – FACIAL (B) – 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

8 – VESTIBULOCOCHLEAR (S) – whispered words heard within 3 ft bilaterally, vibration heard equally well in both
ears, AC>BC, maintains balance even when eyes are closed

9,10 – GLOSSOPHARYNGEAL, VAGUS (B) – Uvula and palate rise symmetrically when client says “ah”, gag reflex present,
swallows s difficulty

11 – SPINAL ACCESSORY (M) – Equal shoulder shrug against resistance, turns head in both directions against
resistance

12 – HYPOGLOSSAL (M) – Protrudes tongue in midline, able to push tongue blade to R and L s difficulty

DEEP TENDON REFLEXES:

SUPERFICIAL REFLEXES: abdominal: cremasteric: plantar:

PATHOLOGIC REFLEXES: brudzinki's sign: Kernig's sign: