GORDON’S FUNCTIONAL HEALTH PATTERNS

FOLLOW THIS FORMAT IN FORMULATING YOUR GORDON’S ASSESSMENT.

YOUR OUTPUT MUST BE ENCODED AND SUBMITTED ON THE DATE SET BY YOUR
INSTRUCTOR.

Name: _____________________________ Area: _______________ Date:

___________________Patient: _______________________ Age: ______ Diagnosis:_________________
____________Instructor: _________________________ Rating: ______________

I. HEALTH PERCEPTION/HEALTH MANAGEMENT PATTERN

II. NUTRITIONAL/METABOLIC PATTERN

III. ELIMINATION PATTERN

IV. ACTIVITY/EXERCISE PATTERN

V. SLEEP/REST PATTERN

VI. PERSONAL HABITS

VII. COGNITIVE/PERCEPTUAL PATTERN

VIII. SELF-PERCEPTION PATTERN

IX. SEXUALITY/REPRODUCTIVE PATTERN

X.COPING/STRESS MANAGEMENT PATTERN

XI. VALUES/BELIEF PATTERN

1.) Health Perception/Health Management Pattern

1)Reason for admission:

What is your understanding of the purpose of the treatment? How do you think the treatment is
working?
3)Have you ever been hospitalized before? For what reason/s?
4) What expectations do you have about this hospitalization?
a. In general, how is your health?
b. What do you do to stay healthy?
c. Do you drink alcohol or use tobacco products? (If yes, ask how many sticks in a day and for how
long now)
d. Any surgeries? (If so, ask when, where, what kind)
e. Do you have regular check-ups with your physician and/or specialists (Pediatrician,
Ob/Gyn,Cardiologist, etc.)?
f. Do you listen to and follow any suggestions made by your health care providers?
g. Last physical check-up (When, why, what was the outcome)h. Any medications taken (What, why, for how
long)i. Any immunizations? (What kind, when)

2. Nutritional-Metabolic Pattern
a. Describe your typical daily food intake? (How many times a day, what kinds of food, etc.)
b. Do you consider yourself a healthy eater?
c. Do you skip meals? (Why)
d. Do you avoid any kind of food? (Why)
e. Do you have any food allergy? (If yes, to what kinds of food)
f. Describe your typical daily fluid intake?
g. Do you drink alcohol? (If yes, what kind and how often)
h. Do you consider yourself over or under weight?
i. Is there any unexplained weight gain or loss?
Indicate any food allergy or intolerance. Record the daily intake of caffeinated
beverages.
1)How is your appetite?
2)Describe what you eat in a typical day.
3)Do you have food restrictions or special diet due to allergies, food intolerance, religious
practices, or other health problems?
4)What vitamins or supplements do you take?
5)What are your food preferences? Likes and dislikes?
6)How often do you go to fast food restaurants?
7)Do you experience any discomfort in eating or swallowing?
8)Do you have dental problems?

3. Elimination Pattern

a. Describe your regular bowel elimination pattern? (Frequency, Character, D

i s c o m f o r t , Difficulty)
b. Have you used or is currently using any laxative? (If yes, why)
c. Describe your regular urinary elimination pattern? (Frequency, Discomfort, Problems withcontrol,
Color, Odor, Any discharges)
d. Any other previous problems with elimination, either bowel or urine? (If yes, when, what
wasdone, for how long)
1)What is your regular bowel movement pattern?
2)Which of the following do you experience? _____ Constipation _____ Diarrhea _____ Ostomy
3)How is your urinary elimination pattern?
4)Which of the following do you experience? _____ Incontinence _____ Dysuria _____ Burning
sensation _____ Dribbling _____ Nocturia _____ Oliguria _____ Polyuria _____ Urinary retention
_____ Catheter present
5)Urine color: __________
6)Do you have any of the following skin problems? _____ Dryness _____ Poor skin turgor _____
Rashes _____ Lesions _____ Swelling _____ Acne _____ Temperature change
7)Do you experience excess perspiration and odor problems?

4. Activity-Exercise Pattern

a. Do you exercise? What type? How often? If not, why?

b. What do you like to do in your spare time?
c. What sports do you participate in?
d. Do you experience any difficulties when you exert effort in any physical activity?
(Describe,when, what happened, what was done)
e. Any changes in your heartbeat when you engage in any physical activity?
Describe a typical day’s activity.
2)What are your usual leisure activities?
3)Do you have regular exercise pattern? Type? Frequency? Intensity? Duration
4)Describe any problem you have experienced with usual activity and exercise?
5.Do you experience the following: Chest Pain? _____ Arm Pain? _____ Leg Pain? _____Back
Pain? _____Difficulty in breathing (dyspnea, wheezing, orthopnea)? _____ Cough? _____
Tingling/Numbness? _____Lightheadedness? _____ Fatigue/Weakness? _____ Palpitations?
_____
6)Factors affecting activity tolerance: Do you smoke? _____ If YES, what are the estimated packs
per year? _____

5. Sleep-Rest Pattern

a. Do you feel that you are generally well rested and able to perform your daily activities?
b. How well do you fall asleep? Stay asleep?
c. Do you use any aids to help you sleep? (Music, medications, reading a book, etc.)
d. Do you awaken feeling rested and ready to take on the day?
e. Usual sleeping hour.
f. How much sleep do you get in a day? (describe pattern – siestas, night sleep, dozing off whilesitting on a couch,
etc.)
1)Time of arising? _____ Time of retiring? _____ Do you take naps? _____ If YES, how long?
_____How often? _____
2)In general, do you feel well-rested and ready for daily activities after sleeping? _____
3.Do you have aids to help you sleep? _____ If YES, what? ____
4.Do you have dreams or nightmares? _____ If YES, what kind? _____
5.Do you experience insomnia? _____ If YES, how often? _____

6. Cognitive-Perceptual Pattern

a. Does you have any difficulty hearing others?

b. Does you have difficulty seeing? Do you have routine eye exams?
c. How do you learn best? Preference for visual or audio aids? Do you have difficulty learning?
d. Any difficulties in making sentences?
e. Any experience of memory loss? (If yes, when, what happened, what was done)
f. Note client orientation to Time, Place, People, and Event.
Eyes and vision last examination result? _____ Do you wear glasses/contact lenses? _____
Do you experienceblurring? _____ Diplopia? _____ Pain? _____ Inflammation? _____ Cataract?
_____ Glaucoma? _____Headache? _____ Photophobia? _____ Unusual discharges? _____
Describe them: ________________________
2)Ears and hearing limitations: Pain? _____ Tinnitus? _____ Describe discharges:
___________________________
3)Other special senses: any problems with
ability to feel pain? _____ ability to feel temperature changes? _____ability to distinguish object
by touch? _____ability to smell? _____ ability to taste? _____
4)Pain: are you experiencing pain? _____ if YES, describe the location: _____ type: _____ How
does the painaffect your daily activities?

7. Self-Perception – Self-Concept Pattern

a. What is your self-perception about yourself?

b. Most of the time, do you feel good about yourself?
c. Do you ever feel that you have lost hope?
d. Are you satisfied with your body image?
e. Do you like to groom? How often?
How do you feel about yourself most of the time?
__________________________________________________
2)Is there something about yourself or your appearance that you like to change?
____________________________
3)How does your illness affect the way you feel about yourself or your body?
______________________________
4)What things make you anxious? _______________ Fearful? _______________ Distressed?
__________________
5)What do you do to alleviate your feelings?

8. Roles-Relationships Pattern

a. Who do you live with? Alone, family, others? What was the family structure in which you grewup? (Nuclear,
Extended, Broken, with Second family)
b. Do you belong to social groups? Do you interact with others outside of work or school?
c. If you were hospitalized, who would perform your responsibilities at home?
d. Who makes the decisions in your family?
e. What about your decisions in family matters?
4)Who do you turn to for help? ______________________________
5)Do family members depend on you? _____ How are they managing while you’re ill?
____________________
6)How would you describe your role in the family?
7)How has your health status affected your relationship with others?
___________________________________
8)What feelings have family members and friends expressed about your illness and
hospitalization?

9. Sexuality-Reproductive Pattern
a. How would you describe your sexual relationship? Satisfying? Changes? Problems?
b. Are you sexually active?
c. Female: Describe menstruation cycle. Problems? Last menstrual period? Para? Gravida?
d. Male and Female: Do you still plan on finding someone to spend the rest of your life with?
(If without a spouse anymore)
Do you take contraceptives? _____ Have you had any problems with using contraceptives? _____
3)When was your last menstrual period? ____
4)Do you have any of the following problems: amenorrhea _____ dysmenorrhea _____ profuse
bleeding _____irregular menstruation _____
5)When was your last pap smear? _____ how often do you undergo pap smear? _____
6)Do you perform breast self-examination? _____
7)Do you have children? _____ if YES, describe your complaints:
11)Have you ever had infections of the reproductive tract? _____ if YES, what are they? _

10. Coping-Stress Tolerance Pattern

a. Any big changes in the past year or two?

b. Who is most helpful in talking things over? Are these people / Is this person
frequentlyavailable to you?
c. Do you use any medications, drugs, or alcohol when stressed?
d. How often are you stressed?
e. What do you do (coping mechanism) when you are stressed?
f. What is your opinion about crying, angry and violent when a person is stressed?
Situations that cause stress in the past?
3.Situations that case stress in the present?
4)How do stressful situations affect you?
5)How do you usually solve your problems?
6)How do you relieve tension and deal with stress?
7)Who do you turn to for help during personal crisis?
8.)Are you able to handle problems successfully most of the time.

11. Values-Beliefs Pattern

a. What is your religion?

b. Is religion important in your family’s life?
c. Does this help when you are faced with difficult situations?
d. Describe your plans for the future. Do you generally get what you want from life?
e. Do you pray? (How often, Where?)
f. Do you feel that at this point in your life, you are one with God? (State the reason)
What are the most important things to you?
2)Do you generally get what you want in life?
3.What are your plans for the future?
4)Do you find prayer and meditations helpful?
5. Has being sick affected your belief and your religion with God:
6)Use FICA questions to incorporate the person’s spiritual values into the health history:

A.Faith: Does religious faith or spirituality play an important role in your life? Do you consider
yourself a religious or spiritual person? _____
B. Influence: How does your religious faith or spirituality influence the way you think about your
health orthe way you care for yourself? _____
C. Community: Are you part of any religious or spiritual community or congregation? _____
D. Address: Would you like me to address any religious or spiritual issues or concerns with you?