DETAILED HEALTH DOCUMENTATION OF A HEALTHY PERSON

HEALTH HISTORY

Past Health History (Healthy Client)

Client M.M. had a mumps chicken pox when she was 7 years old in 2006, her mother
told her to put vinegar with a mixture of blue dye. The client has a fever yearly with duration of
3 days and takes 1 dosage of paracetamol in a day. The client has no recorded injuries, accidents,
adult illnesses and has no drug sensitivities and allergic reactions to any foods, plants and
animals. The client is not taking any herbal medicines. The client is a fully immunized child
(FIC). The client did not undergo on any kind of examination.

Gordon's 11 Functional Health Patterns (Healthy Client)

A. Health Perception-Health Management Pattern

The client stated that she asks for advices from her mother whenever she feels sick. The
client’s last drink of alcohol was on January 2022. The most important things that keep her
healthy were eating three times a day, taking a walk, drinking lots of water, and doing
household chores. No usage of tobacco was stated by the client. The client has no problems
with cuts and healing. As stated, the client experiences tinnitus on both ears 10-15 minutes
every 2 months. The client does not perform breast self-examination.
Interpretation: No deviation from normal

B. Cognitive Perceptual Pattern

The client appears alert, and calm and doesn’t experience numbness or tingling sensation
on any part of the body. The client stated that she hasn't made any important choices that were
both easy and tough. The client has no difficulty upon reading a handheld material with a
distance of 2ft. The client has a vision of 20/20 upon using the Snellen chart and has no
history of eyeglass use. The client has no overt signs of pain.
Interpretation: No deviation from normal
C. Self-Perception and Self-Concept Pattern
The client rated her anxiety from 5 out of 10 without any signs of anxiety upon
observation. The level of assertiveness and level of control in situations is rated by the client
as 7 out of 10. The client does not show any unusual body language. The client views herself
as a positive and healthy woman and stated that she currently does not have any major health
concerns. The client appears calm, shows readiness in answering the questions, and does not
hesitate to talk with soft and normal voice quality.
Interpretation: No deviation from normal

D. Role Relationship Pattern

The client belongs to a nuclear family type; her Mother, Father, and 2 siblings. The
client’s family shows good affection towards each other and does not show any form of
dysfunctional family interactions upon observation. She stated that she is active in terms of
social activity that includes interaction with her neighbors and friends. The client is
unemployed and has a history of employment as an operator of a company. The client’s
support system includes her live-in-partner, neighbors, and other members of the family.
Interpretation: No deviation from normal

E. Sexuality and Reproductive Pattern

The client does not undergo a pap smear ever since and has no history of sexually
transmitted disease. She is not experiencing any problems in sexual functioning and is
satisfied with her sexual relationship.
Interpretation: No deviation from normal

F. Coping and Stress Tolerance Pattern

The client appears without any signs of stress upon observation and stated that her
primary way to deal with it is through talking with her friends. Usage of cellular phone and
bonding with her boyfriend is considered by the client as her stress releasing activity. She
rated her usual handling of stress as average. The client is satisfied with the care that she is
receiving at home and has not experienced any traumatic events in the past years. Financial is
the major concern of the client regarding hospitalizations.
 Interpretation: No deviation from normal

G. Value and Belief Pattern

The client stated that her religion is Born Again and has no religious restrictions. She
believes that the interview will not interfere with any of her spiritual or religious practices as
well as with her plans in the future.

H. Nutritional Metabolic Pattern

The client’s weight is 52kg and has a height of 158cm. She has gained weight for about
4kg in the last 6 months. Good appetite was stated by the client and drinks 6-7 glasses of
water every day. She has no problem with nausea, vomiting, swallowing, chewing, and
indigestion. Client describes her lifestyle as active.

February February February February February February February

14, 2022 15, 2022 16, 2022 17, 2022 18, 2022 19, 2022 20, 2022
(M) (Tue) (W) (Thu) (F) (Sat) (Sun)
Breakfas egg 2 pcs 2pcs milk 2 pcs 1 serving egg
t (7am) (2pcs regular pandesal pandesal (1 glass) pandesal of sinigang (2pcs
sized) with 2 cups regular
rice sized)
Lunch 1 serving 1 serving 1 serving 1 serving 1 serving 1 serving 1 serving
(12am) of of tinola of toge of chicken of sinigang of adobo of fried
pinakbet with 1 with 1 cup tempura with 2 cups with 2 cups chicken
and fish cup rice rice with 2 cups rice rice with 1
with 1 rice cup rice
cup rice
Dinner 1 serving 1 serving 1 serving 1 serving 1 serving 1 pc 1 serving
(8pm) of fried of tinola of of sinigang of sinigang bangus of
chicken with 1 kangkong with 2 cups with 2 cups daing with tocino
with 1 cup rice with 1 cup rice rice 2 cups rice with 1 cup
cup rice rice rice

Interpretation: No deviation from normal

I. Elimination Pattern
The client’s usual bowel movement is 3 times a week every morning. As described by
the client, her stool was usually soft and brown. The client had diarrhea last September 12,
2021, to September 13, 2021 and took an over-the-counter drug diatabs with 1 dosage per day.
No history of constipation, and incontinence as stated by the client. The usual voiding pattern
was 6-7 times per day. As described by the client, her urine was light yellow with an aromatic
odor. The client does not experience nocturia during the night. She does not experience
discomfort during urination and no excessive perspiration upon observation.
Interpretation: No deviation from normal

J. Activity and Exercise Pattern

The client rated bathing, grooming, general mobility, toileting, home maintenance, bed
mobility, dressing, and shopping 1 as completely independent. The client considered
household chores as her exercise every day.
Friday February 16, 2022 Activities
8:00 am wakeup
6:30 am household chores
9:00 am eat breakfast
9:30 am household chores
10:00 am prepare lunch
12:00 pm eat lunch
12:30 pm use of cellphone
2:00 pm take a nap
5:30pm prepare dinner
6:00pm eat dinner
7:30 pm wash dishes
8:30 pm take a bath
9:00 pm sleep
Saturday February 17, 2022
8:00 am woke up
9:15 am prepare breakfast & lunch
10:00 am eat breakfast
11:00 am household chores
12:00 pm eat lunch
12:30 pm use cellphone
4:00pm laundry
 6:00pm prepare dinner
7:30 pm eat dinner
8:30 pm take a bath
9:00 pm sleep
Sunday February 18, 2022
6:00 am woke up
6:30 am household chores
9:00 am watch television and eat breakfast
9:30 am use cellphone
10:00 am take a bath
12:00 pm eat lunch
12:30 pm use of cellphone
4:00 pm- take a nap
6:30 pm eat dinner and watch tv
7:30 pm take a bath
9:30 pm sleep

Interpretation: No deviation from normal

K. Sleep and Rest Pattern

The client’s usual sleep habit is 10 hours per night from 9:30 pm – 8:00am and usually
naps in the afternoon from 2pm-4pm. The client has no difficulty in sleeping and awakens
during the night because of the baby. Yawning during the assessment not observed.
M T W TH F S SU
Time went to 9:00 pm 10:00pm 9:00 pm 9:00 pm 9:00 pm 9:00 pm 9:30 pm
bed
Approximate 15 mins 25 mins 10 mins 10 mins `15 mins 15mins 10 mins
time fell
asleep
Wake up N/A N/A N/A N/A N/A N/A N/A
period/ sleep
interruptions
Time 8:30 am 8:00 am 8:00 am 9:30 am 8:00 am 8:00 am 6:00am
wakeup
Feeling after Feeling Feeling Feeling Feeling Feeling Feeling Feeling
waking up rested rested rested rested rested rested rested
Naps (time No nap No nap 1½ No nap 3½ No nap 3½
slept & woke hours hours hours
up; duration)
Bed time  pray  Drink  Drink  Drink  Use of  Drink  Use of
rituals milk milk choco scented milk scented
 Use of  pray  pray candles  pray candles
scented  pray  pay
candles
 pray

Interpretation: No deviation from normal