BIOGRAPHIC DATA you?

-Are you consulting “albularyos”?

Name: Marital Status: • How do you perceive health now that you are sicked?
Age: Occupation: 2) Nutritional metabolic pattern
Gender: Religion: • Are you taking a balanced diet?
Address: Health care • What's your typical daily diet?
resources: • How many cups of rice were you taking during breakfast?
lunch?dinner?
• Do you experienced any difficulty in swallowing?
CHIEF COMPLAINT • Are there times that you feel lost your appetite in eating?
• Are there some health problems bothering you? Among When was that?
them, which is your main concern right now? • What's your favorite food?
HISTORY OF PRESENT ILLNESS • Do you have allergic reaction with any food?
• When does the symptom started? • Do you take snacks in between meals?
• How often it occurs? • How many glass of water are you taking daily?
• Does it happengradually or suddenly? • Are you taking any vitamin?
• What are you doing when you feel the unusual things? • What's your weight? Is there an improvement compared to
• Kindly specify to me the parts of your body that are being the previous one?
affected? • How about your height? Do yohow about its u think it is
• If you rate the pain you experienced from 1 to 10,what aproppriate with your age?
number would it corresponds? • What's your body temperature daily?
• Are there things that when you do such, the pain was being • Do you have any skin disease?
aggravated/alleviated? • If you are wounded,does your skin easily healed?
PAST HISTORY • Are there changes in your normal pattern of eating now
• What are the illnesses you experienced during your that you got sicked?
childhood days? 3) Elimination pattern
• Did you undergo any form of vaccinations already? Please • How many times you urinate aeveryday?
specify. • Can you tell me the amount of your urine in terms of liter?
• Have you experienced any serious illnesses before? • Do you feel any pain?
• Do you have any kind of allergies? What do you do when • Kindly describe to me the color of your urine? Is it
you experienced having one? transparent?
• Prior to this, did you meet any accidents already? Or • How about its odor?
injuries? • How many times you defacate in a week?
• When did it happen? • Is there a pattern in your elimination?
• What part of your body was affected? • Kindly describe to me the color of your stool? Is it hard or
• What kind of accident or injury was it? soft?
• What are the treatment you received? • How about its amount?
GORDON'S FUNCTIONAL HEALTH PATTERN • Are you using any laxatives or diuretics?
4) Activity exercise pattern
1) Health perception health management model • What are your daily work?
• What is a healthy person for you? • Do you think you have enough energy for these daily
• Is health important to you? activities?
• How do you value your health? • What do you usually do during your free time?
• How often do you visit your doctor? • Are you performing exercises or any sort of it?
• What are the different ways you perform to maintain • How often do you do them?
proper hygiene? • How do you usually feel after performing such activity?
-Do you take a bath everyday? • Is there a change in your respiration?
-How many times you brush your teeth? • Do you experience any unusual changes?
-Do you change your clothes regularly? -is there any difficulty in your breathing?
• Do you smoke? -do you experience any muscle ache?
• Do you use alcohols? -doyou feel dizzy?
• What do you usually do when you're sick? • do you get easily tired?
-Do tou take OTC drugs? • Kindly tell me the changes happened in your usual
-Do you take drugs or medicines which are not prescribed for activities now that you are sick compared before?
 5) Sleep rest pattern do you usually do to relieve the pain?
• Do you think you have a healthy sleep pattern? • If you are single,what do you usually do to satisfy your
• How many hours do you sleep? needs as a male?
• Do you sleep continously? Or are there interruptions in • Do you perform self breast examination?
between? • Do oyu perform testicular self examination
-do you get up at night to go to the bathroom? 10) Coping stress tolerance
• What time do you sleep at night? • What do you do when you feel stressed?
• What time do you wake up in the morning? -do you eat too much,take a nap, cry, hit yourself or what?
• How many minutes do you take a nap during daytime? • Are you fond of attending 'gimiks' or any recreational
• Are you taking sleeping tablets? activities?
6) Cognitive-perceptual pattern • Does it help you feel relieved?
• Are you having a monthly check up with your different • Do you usually ask help from others ?about 5 pads a about
senses? 5 pads a
• Can you see things clearly? • What are the things that give/make you fatigue?
• Are you nearsighted/farsighted?
• How long are you using your eyeglasses/contact lenses, 11) Value belief system
since when? • Do you believe that there's god?
• Do you hear things clearly? • What aws your religion?
• Can you distinguish one smell from another? • Do you communicate with him? Through what?
• Can you decipher the four different taste? • Are there any superstitious beliefs
(sweet,bitter,salty,sour) you usually do related to health?
• What is your favorite subject before when you were in • In your religion, are there medical
grade school? practices which are not allowed?
• What did you do before going to this appointment?
• Do you have difficulties in remembering things,e.g, where
do you put that thing?
7) Self perception self concept pattern
How do you feel about yourself?
• Are you contented on being you? How?
• Kindly tell me what are your greatest achievements as of
now?
• Do you believe in your self? How high is your self esteem?
• Are you looking to yourself as superior to others?
• When you talk to somebody,are you having an eye to eye
contact with him/her?
• Kindly tell me what are your talents/weaknesses?
• What are youf fears in life?
• Which do you prefer most of the time, to be alone or to be
with many people?Why?
8) Role relationship pattern
• How is your relationship with your family?(to your
brother,sister,parents)
• Do you feel comfortable at your house?
• Do you greet or give gifts to your loved ones when the
celebrate special ocassions?
• How do you fulfill your responsibilities at your house?
9) Sexuality reproductive pattern
• Do you have any problem with your reproductive system?
• Are you married? If yes,how often do you have sexual
intercourse?
• Are you satisfied after the intercourse?
• Do you have a regular menstrual period?
• How many pads do you consume in a day?
• During those times, are you having a dysmenorrhea? What