GORDON’S FUNCTIONAL HEALTH PATTERNS

INDIVIDUAL ASSESSMENT
Health Perception/Health Management
1. How has your general health been?
2. If appropriate: Most important things done to keep healthy?
3. Allergies?
4. If person has an illness:
a. Action taken when symptoms perceived? Did that help?
b. What do you think caused this illness?
c. Medications taken currently? Names? Dose? Times?
- Problems in getting or taking these?
- Seem to be helping?
- Did you bring them with you?
5. Use herbs or other traditional family remedies?
6. Colds in the past year?
7. Absences from work or school lasting longer than 1 week?
8. Monthly breast self-examination?
9. Prostate screening?
10. Bone density?
11. Colonoscopy?
12. If in high-risk group:
a. Flu and pneumonia vaccinations?
b. Tetanus booster?
c. Hepatitis?
d. Other age-appropriate immunizations?
13. Use cigarettes? Drugs? Alcohol? When was your last drink?
14. Accidents in the past year, either at home, work, or while driving? Wear seat belts?
15. Falls in the past year?
16. In the past, easy to find ways to follow doctors' or nurses' suggestions about health
management?
17. If appropriate: What things are important to you while you are here? How can we be
helpful?

Nutritional-Metabolic
1. Typical daily food intake?
2. Supplements? Vitamins? Type and timing of snacks?
3. Weight stable? Loss or gain, including amount?
4. Height loss, including amount?
5. Appetite?
6. Food or eating discomfort? Problems chewing or swallowing?
7. Food coming back?
8. Diet restrictions? Able to follow restrictions?
9. If appropriate: Breastfeeding?
 10. Typical daily fluid intake?
11. Heal well or poorly?
12. Skin problems: Lesions, dryness?
13. Dry mouth?
14. Dental problems? Bleeding gums? Frequency of dentist visits?

Elimination
1. Bowel elimination pattern: Frequency? Character? Discomfort?
2. Problem in control?
3. Lose bowel contents when unwanted?
4. Use of laxatives? Other methods to maintain regularity?
5. Urinary elimination pattern? Frequency?
6. Trouble holding urine until getting to bathroom?
7. Lose urine when unwanted, such as after sneezing, coughing, or laughing?
○ If yes: Wear a pad?
8. Excess perspiration? Odor problems?
9. Body cavity drainage from catheter, ostomy, or suction?

Activity- Exercise
1. Sufficient energy for desired and required activities around work, school,and home?
2. Describe activity level for most days of the week:
Very active.
Moderately active.
1 Mostly sedentary.

3. Exercise pattern? Type? Regularity? Hours per week?

Cognitive-Perceptual
1. Discomfort or pain? (If present, describe intensity using Wong-Baker Faces Pain Rating
Scale, Numeric Rating Scale, or Descriptive Rating Scale below.)
2. Location? Quality? When does it occur? When started? What makes it worse?
 3. What seems to help when this occurs? Effective most of the time?
4. Difficulty in vision or reading?
5. Wear glasses? Last time vision checked? Bring glasses with you?
6. Use contact lens?
7. Difficulty hearing?
○ If yes: Use hearing aid? Use frequently?
8. Exposed to loud noise or music?
9. Changes in taste of food?
10. Changes in sense of smell?
11. Changes in feeling or touch in toes, feet, hands?
12. Change in memory?
○ If yes, recent things? Things from the past? How do changes interfere with
activities?
○ If suspect memory impairment, ask today's date, day of the week, current
President, and name of present location.
13. Problems concentrating?
○ If yes: Feel this interferes with tasks or work?
14. Decisions easy or difficult to make?
○ If difficult, ask patient to describe the difficulty.
15. Difficulty learning?
16. Easiest way for you to learn? What helps?
17. Level of school completed?

Sleep-Rest
1. Generally feel rested and ready for daily activities after sleep?
2. Sleep onset problems? Sleep aids used?
3. Dreams or night awakening?
4. Snoring? Headache when awakening?
5. Ever doze off for a second while driving? When stopped at a light or stopped in traffic?
Dozing during the day?
6. Usual bedtime? Bedtime routines?
7. Rest-relaxation periods during the day or evening?

Self-Perception/Self-Concept
1. We all have an idea of ourselves. How would you describe yourself?
2. Most of the time feel good or not so good about yourself?
3. Changes in your body or the things you can do? Are these a problem for you?
4. Changes in way you feel about yourself or your body since illness started?
5. Find things frequently make you angry? Annoyed? Fearful? Anxious? Depressed? What
helps when this happens?
6. Ever feel you lose hope?
7. Ever feel you are not able to control things in life? What helps?

Role-Relationship
 1. Live alone? Family structure?
2. Problems in either the nuclear or extended family you have difficulty handling?
3. How are problems usually handled?
4. Family or others dependent on you? How are they managing while you are here?
5. If a long-term care provider: Ever get very angry and stressed with the person you are
caring for?
6. Recent losses?
7. If appropriate: How are family and friends responding to your illness?
8. If patient has children: Problems with children? Difficulty handling problems?
9. If appropriate and if married or living with partner: How do you and your partner settle
arguments?
10. Do you feel safe in your current relationship?
11. Belong to social groups, such as religious groups, or clubs?
12. Close friend you can confide in?
13. Ever feel lonely? If yes, how often do those feelings occur?
14. Things generally go well at work? School?
15. Income sufficient for needs?
16. Feel part of (or isolated from) the neighborhood?

Sexuality-Reproductive
1. Is your sexual relationship satisfying? Problems?
2. Use of medications to influence sexual performance?
3. Use of safe sex practices? Always? Sometimes? Never?
4. If appropriate to age: Use family planning methods? How long?
5. Problems?
6. Female: At what age did menstruation start? Last menstrual period? Problems?
7. Female: Para? Gravida?
○ Para refers to the total number of pregnancies that a female has carried beyond
20 weeks gestation (whether viable or nonviable)
○ Gravida indicates the number of times a woman is or has been pregnant

Coping/Stress Tolerance
1. Have someone helpful in talking things over? That person available to you now?
2. Tense or relaxed most of the time? What helps?
3. Use medicines, drugs, or alcohol to relax?
4. Big changes in your life in the last year or two?
5. When problems occur, how do you handle them? Most of the time, is this way
successful?

Value-Belief
1. Generally get things you want out of life?
2. Most important things in your life?
3. If appropriate: Plans for the future?
4. Religion important in your life?
 ○ If yes: Does this help when difficulties arise? Will being here interfere with any
religious practices?
5. As you are concluding the history or following the examination, ask the following:
○ For the patient who is hospitalized: Things that are important to you while you are
here? Maybe things we did not discuss?
○ For the patient at a clinic visit: Things important to you at this visit that we did not
discuss?

FAMILY ASSESSMENT
Health Perception/Health Management
1. Family's general health in last few years?
2. Family members' colds in the past year?
3. Absences from work or school?
4. Most important things a family does to keep healthy? Do these make a difference to
health? (Include family folk remedies.)
5. Family members' immunizations? (Check the status of adults and children.)
6. Regular health-care provider? Frequency of checkups? Adults? Children?
7. If children in the house: Storage of drugs and cleaning products? Disposal of drugs?
8. Scatter rugs at home? Other home hazards?
9. Accidents in the past year, either at home, work, school, or while driving?
10. In the past, was it easy to find ways to carry out doctors' or nurses' suggestions?
11. Other things in the family's health that are of concern?

Nutritional-Metabolic
1. Typical family meal pattern and food intake?
2. Supplements, including vitamins and types of snacks?
3. Typical family fluid intake?
4. Supplements, including fruit juices, soft drinks, and coffee?
5. Family member's problem with appetite?
6. Frequency of dental care of both adults and children?
7. Family members with skin problems? Wounds, cuts, scratches, or healing problems?
8. When opportunity available, check the following:
○ Food types in the pantry?
○ Refrigerator contents and temperature?
○ Meal preparation practices?
○ Contents of meals?

Elimination
1. Problems in waste and garbage disposal?
2. Adequate disposal of pet waste, both indoor and outdoor?
3. Problems with flies, roaches, rodents, or indoor air pollution?
4. Able to get adequately hot water for washing dishes and clothes?
Activity- Exercise
1. Problems in:
Shopping, including transportation to and from the store?
Schedule keeping for members, such as for children's activities?
Cooking and meal preparation?
Keeping up the house?
Budgeting income for food, clothes, home, and other costs?
2. Approximately how many hours per week do family members find time to exercise?
Type? Regularity?
3. Family leisure activities? Active activities, such as sports and walking, or passive
activities, such as television and computer games?
4. If relevant: Any difficulty managing caretaking activities of children or other dependent
family members, such as those with a disability?

Cognitive-Perceptual
1. Family members with visual or hearing problems? How is it managed?
2. Important family decisions made in the last few years? How was it made? Members
involved?
3. Language spoken?

Sleep-Rest
1. Most days, do family members seem to be well rested and ready for school and work?
2. Regularity of family sleep pattern?
3. Sufficient space? Quiet, dark sleeping space available?
4. Young baby in family? Toddler asking to sleep in parents' bed?
5. Family members find time to relax before sleep?

Self-Perception/Self-Concept
1. Family members living at home?
2. Extended family in close touch?
3. Most of time family members feel good or not so good about themselves as a family?
4. General mood of family? Happy? Anxious? Depressed?
5. What helps improve family mood?

Role-Relationship
1. Family or household members: List ages of members and family structure.
2. Current problem in either the nuclear or extended family that is difficult to handle?
3. If with children: Child-rearing problems? Problems guiding teenagers?
4. Members respect the privacy of other family members?
5. Number of meals family can eat together per day?
6. Do families have joint recreational activities?
7. Relationships among family members? Among siblings? Between parents? Extended
family?
8. Members support each other?
 9. Income sufficient for family needs?
10. Feel part of (or isolated from) community? From neighbors?
11. Any adult-dependent members requiring care? Who is the caregiver? Any problems?

Sexuality-Reproductive
1. If with sexual partner within household or situation: Are sexual relations satisfying?
Problems?
2. Elderly married: Changes in your and your partner's interest in sex?
3. Unmarried: Problems regarding sex?
4. Use of family planning?
5. Using contraceptives? How long? Problems in use?
6. If appropriate: Is it easy to find time and privacy for intimacy?
7. If with children of appropriate age: Feel comfortable in explaining or discussing sexual
subjects with your children?
8. If with children of appropriate age: Children sexually active? Know about safe sex?

Coping/Stress Tolerance
1. Big changes or difficult situations within the family in last few years? If with changes:
How did the members adapt to the change?
2. Family tense or relaxed most of the time? If tense, what helps?
3. Anyone use medicines, drugs, or alcohol to decrease tension?
4. When everyday family problems arise, how are they handled? Most of the time, is this
successful?
5. Family plans for communicating and managing emergencies?

Value-Belief
1. Family generally gets things it wants out of life?
2. Important things for the future?
3. Family rules about behavior that everyone believes are important?
4. Religion important in family?
a. If yes: Does religion help when difficulties arise?