ASSESSMENT TOOL

Name of Student: __________________________ Level __ Section __ Rating: ______

I. Nursing Health History

A. Biographic Data
Initials of Client/Patient :
Residence: _____________
Contact Number: Nationality:
Religion : Birth of Date:
Age: Sex: Civil Status:
Educational Attainment: ______
Occupation: _____________

Name of Hospital: ___________________ Ward & Room No.:

Date of Admission: Attending Physician :

Impression / Admitting Diagnosis:

__________________________
Source of Information:
( ) Patient
( ) Others, (Initials of SO):
Relationship to patient :

B. Admitting Complaint/s
_____________________________________________________________________________________
_________________________________________________________________________

C. History of Present Illness

Symptom: ______
Location: ______
Character: ______
Intensity: ______
Timing: _____________
Aggravating factors:
Alleviating factors:
Treatments tried:

D. Past and Present Medical History (Utilizing Gordon’s Functional Health Pattern).

Before During
Gordon’s Criteria Admission Admission
I. HEALTH PERCEPTION HEALTH MANAGEMENT
PATTERN
 Before During
Gordon’s Criteria Admission Admission
II. HEALTH PERCEPTION HEALTH MANAGEMENT
PATTERN

III. NUTRITIONAL-METABOLIC PATTERN

IV. ELIMINATION PATTERN

IV. ACTIVITY-EXERCISE PATTERN

Criteria Rate Criteria Rate Criteria Rate

Feeding Gait Cooking
Bathing ROM Shopping
Toileting Grooming Bed mobility
Home maintenance General mobility Posture
Dressing Hand Grip

Functional Level Codes

*Level 0: full self-care
*Level I: requires use of equipment
or device
*Level II: requires assistance or
supervision from another
person
*Level III: requires assistance or
supervision from another
person and equipment or
device
*Level IV: is dependent and does not
participate

Before During
Gordon’s Criteria Admission Admission
V. SLEEP-REST PATTERN

VI. COGNITIVE-PERCEPTUAL PATTERN

VII. SELF-PERCEPTION—SELF-CONCEPT PATTERN

VIII. ROLES-RELATIONSHIPS PATTERN

Draw the family structure or genogram with emphasis

on the specific heredo-familial diseases.

Before During
Gordon’s Criteria Admission Admission

IX. SEXUALITY-REPRODUCTIVE PATTERN

G___ T___ P _ A L___ M___

X. COPING-STRESS TOLERANCE PATTERN

XI. VALUES-BELIEFS PATTERN

XII. Other concerns: Any other things we haven’t

talked about that you would like to mention?
Any questions?