H. ROLES-RELATIONSHIP PATTERNS: -Use any medications, drugs, alcohol to relax?

-Live alone? -When (if) there are big problems in your life, how do you handle them? Most of
-Family? Family structure? Any family problems you have difficulty handling the time, are these ways successful?
(nuclear/extended family)? Family or others depend on you for things? How well
are you managing? K. VALUES-BELIEFS PATTERN:
-If appropriate – How families/others feel about your illness? -Generally get things you want from life?
-Problems with children? -Important plans for future?
-Belong to social groups? -Religion important to you? f appropriate - Does this help when difficulties arise?
-Close friends? Feel lonely? (Frequency) -If appropriate – will being here interfere with any religious practices?
-Things generally go well at work / school? -Health beliefs/values?
-If appropriate – income sufficient for needs?
-Feel part of (or isolated in) your neighborhood?
Examination (examples of objective data):

• Interaction with family members or others if present.

I.SEXUALITY-REPRODUCTIVE PATTERN:
-Kamusta po ang relayon niyo ng asawa/boyfriend niyo? Anu po iyong mga
pagbabago na nakita niyo nung nakilala niyo ang asawa/boyfriend mo?
-Kapag ho may problema o away? Paano niyo po ito nasosolusyonan? Sino po
ang unang humihingi ng sorry?
-If appropriate to age and situation – Sexual relationships satisfying? Changes?
Problems?
- If appropriate – Use of contraceptives? Problems?
-Female – when did menstruation begin? Last menstrual period (LMP)? Any
menstrual problems?
-(Gravida/Para if appropriate)

J. COPING-STRESS TOLERANCE PATTERN:

-Any big changes in your life in last year or two? Crisis?
-Who is most helpful in talking things over? Available to you now?
-Tense or relaxed most of the time? When tense, what helps?
Demographic Data GORDONS
Name: Educational Attainment: A. HEALTH PATTERN MANAGEMENT:
Address: Religion:
-Client’s general health?
Age: Occupation:
Birth Date: Marital Status: -Any colds in past year?
Birth Place: Name of Spouse: -Childhood illnesses? Allergies?
Gender: Number of Children: -If appropriate: any absences from work/school?
Ethic/Race: Chief Complaints: -Most important things you do to keep healthy?
-Yung mga kasama ninyo po sa bahay, sa tingin niyo po malulusog sila?
VITAL SIGNS: -Use of cigarettes, alcohol, drugs?
-BP; TEMP,; RR; PR
-Perform self-exams, i.e. Breast/testicular self-examination?
*kung mataas ang BP patanung kung nagma-maintenance meds. ba siya. -Accidents at home, work, school, driving?
-Na-ospital na po ba kayo? Healthcenter? Bakit po at paano?
PRESENT HEALTH ILLNESS -In past, has it been easy to find ways to carry out doctor’s or nurse’s suggestions?
-Character (how does it feel, look, smell, sound?) - (If appropriate) what do you think caused current illness?
-Onset (When did it begin: is it better, worse, or same since it began?) -What actions have you taken since symptoms started?
-Location/radiation (Where is it? Does it radiate?) -Have your actions helped?
-Duration (How long it lasts? Does it recur?)
-(If appropriate) What things are most important to your health?
-Severity (use rating scale)
-Pattern (What makes it better, worse?) -How can we be most helpful? Done exercise every what?
-Associated factors (What other symptoms do you have with it? Will you be
able to continue doing your work or other activities ?) B. NUTRITIONAL-METABOLIC PATTERN (BEFORE AND AFTER HOSPITALIZATION)
-Ano po ang madalas niyong kinakain?
PAST HEALTH HISTORY -Naalala niyo po ba ang kinain niyo nung nakaraang araw? Last two days ago?
• birth, growth and development -Kumakain po ba kayo ng tatlong beses sa isang araw?Merienda? Anung madalas
• childhood diseases
niyong kinakain kapag merienda? Ilan beses po kayo nagmemerienda?
• immunizations
• allergies --Use of supplements, vitamins?
• previous health problems -Typical daily fluid intake?
• hospitalizations and surgeries -Naalala niyo po ba ang timbang niyo? Tangkad?
• pregnancies -Weight loss/gain? Height loss/gain?
• births -Appetite?
• previous accidents and injuries
• pain experiences
• emotional or psychological problems

-Breastfeeding? Infant feeding? F.COGNITIVE-PERCEPTUAL PATTERN:

-Food or eating: Discomfort, swallowing difficulties, diet restrictions, able to -Hearing difficulty? Hearing aid?
follow? -Vision? Wears glasses? Last checked? When last changed?
-Healing – any problems? Skin problems: lesions? Dryness? Dental problems? -Any change in memory? Concentration?
-Important decisions easy/difficult to make?
C. ELIMINATION PATTERN: (BEFORE AND AFTER HOSPITALIZATION) -Easiest way for you to learn things? Any difficulty?
-Ilan bese po kayong dumudumi sa isang araw? Puwede po bang i-describe yung -Any discomfort? Pain? COLDSPA C - Character O - Onset L - Location D – Duration
dumi niyo? Wala naming masakit habang dumudumi? S – Severity P - Pattern A - Associated factors (Weber, 2003)
-Ilan beses po kayong umiihi sa isang araw? Ano pong kulay ng ihi niyo po? Ano po
ung madalas na kulay? Wala naman pong masakit habang umiihi? Examination (examples of objective data):
-Madala po ba kayong pag-pawisan? Ano po ang mga bagay na ginagawa niyo ng • Hears whispers? Reads newsprint?
nagdudulot ng pawis sa katawan niyo? Wala naman pong body odor? • Grasps ideas and questions (abstract, concrete)?
• Language spoken. Vocabulary level.
D. ACTIVITY-EXERCISE PATTERN: (BEFORE AND AFTER HOSPITALIZATION) • Attention span.
- Sa tingin niyo po may lakas pa po kayong gawin ang mga bagayna gusto niyo?
Kung hindi, bakit? G. SELF-PERCEPTION AND SELF-CONCEPT PATTERN:
-Ano po ang kadalasang ginagawa niyo sa isang araw? Mula umaga, hapon -How do you describe yourself?
hanggang gabi? -Most of the time, feel good (or not so good) about self?
-Nage-exercise po ba kayo? Anong klaseng page-ehersisyo? Gaano kadalas? -Changes in body or things you can do? Problems for you?
-Kapag may spare time po kayo? Ano po ang ginagawa niyo? -Changes in the way you feel about self or body (generally or since illness started)?
-Perceived ability for feeding, grooming, bathing, general mobility, toileting, and -Things frequently make you angry? Annoyed? Fearful? Anxious? Depressed?
home maintenance, bed mobility, dressing and shopping? -Not able to control things? What helps?
-Ever feel you lose hope?
E. SLEEP-REST PATTERN: (BEFORE AND AFTER HOSPITALIZATION)
-Anong oras po kayo natutulog at nagigising? Examination (examples of objective data):
-Natutulog din po ba kayo sa hapon? Mga ilang oras, minute po? • Eye contact. Attention span (distraction?).
-Nagigising po ba kayo kaagad? Dahil sa? • Voice and speech pattern.
-May mga bagay po ba na nagpapagising sainyo? Nagpapatulog? Anu po iyon? • Body posture.
-(Kung may trabaho o galling sa school) Nagpapahinga po ba muna kayo o • Client nervous (5) or relaxed (1) (rate scale 1-5) Client assertive (5) or
diretsong aral o trabaho sa bahay? passive (1) (rate scale 1-5)
-Yung mga panaginip niyo po? Minsan po ba mabubuti o masasama? Ano po ang
kadalasan? Nagigising po ba kayo kaagad kapag masama po ang iyong panaginip?