Demographic Data B.

Past Health History

1. Immunizations
Name:
Address:
Age:
Gender:
2. Past Illnesses
Birthdate:
Birthplace:
Religion:
3. Heredofamilial disease
Place of Origin:
Occupation:
Educational Attainment:
4. Accidents/ Injuries
Marital status:
Name of spouse:
Number of children:
5. Hospitalizations
Chief complaints:

Diagnosis:
6. Diagnostic Procedure

Date of Admission:
Room & Bed number:
7. Travel local and abroad
Attending physician:
Medical Insurance:

Nursing Health History

C. Family History
A. History of Present Illness
Female Deceased X
1. Signs and symptoms
Male Married -- -- --
Divorced --//-- Patient

2. Inclusive Dates

3. Precipitating and alleviating factors

4. Effect to other body parts/functions

5. Intervention/treatment done

6. Effect of intervention/treatment
 GORDON’S HEALTH ASSESSMENT Client’s response
A. Health Perception – Health Management Pattern
• Do you have a regular check- up? How often?
• When you feel sick, do you consult a doctor Or usually
self-medicate?
• Do you follow the prescriptions of the doctor? How
do you feel after?
• Did being sick cost you to absent from work/school?
• How do you perceive health?
• Can you describe to me what you do to be healthy?
Like what do you do in a day, your daily routine?
• Do you perform self-examination at home?
• Do you smoke? Since when?
• Do you drink alcohol? How often?
• Do you take herbal or food/vitamin supplements?
• On the scale of 1-10, how do you rate your health
today? Compared to the past weeks, months or years?

B. Cognitive – Perceptual Pattern Client’s response

• Do you have a hearing difficulty? In both or either of
your ears? If yes, do you use hearing aid?
• Do you have a blurry vision? Do you wear a
prescription glass?
• When was the last time you got your eyes checked?
• Any change in memory? Do you have a problem
concentrating on things?
• What about your attention span, do you have a long or
short attention span? If short, what do you think is the
problem?
• Do you find important decision, easy or difficult to
make?
• What are the ways for you to easily learn things? Like
Visual aids or audio or anything?
• Are you always in your proper state of mind?
• Do you comprehend instructions easily?
• Do you have difficulties or discomfort in speaking?

C. Self-perception – Self-concept Pattern Client’s response

• Do you meet all your potentials?
• Do you maximize your potentials?
• Do you feel contented/satisfied at this moment?
• Are you happily living with your life? Why?
• Do you feel inferior to others? Why?
• Do you feel superior to others? Why?
• Do you have any insecurity to others? Why?
• Do you have enough self-esteem? Why?
• Do you have enough self-confidence? Why?
• What are your strengths and weaknesses?
 D. Role – Relationship Pattern
 What is your role to your family?
 What is your role as a student?
 What is your role as a friend?
 What is your role as a member of the church?
Can you relate to others? Why?
 Are you in a relationship with someone?
 Are you in a good relationship with your family? Why?
 Are you in a good relationship with others?
 How does role or relationship with others
affect your health?
 Who do you feel closest to?

E. Sexuality – Reproductive Pattern

 Do you have a partner?
 How was your relationship with same sex?
 Are you sexually active?
 How do you often masturbate?
 Are you happy being a man?
 Have you had any relationship with a homosexual
before?