Gordon's Functional Health Pattern Format and Guide Questions

JOSE RIZAL MEMORIAL STATE UNIVERSITY | COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES
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
Date Received: __________________ Date Returned: ___________________
Instructor: _____________________ Student’s Name: __________________
Signature: ______________________ Signature: _______________________

GORDON’S ASSESSMENT GUIDE QUESTIONS

1.) Health Perception/Health Management Pattern
Hospitalized Client
1) Reason for admission: ________________________________________________________________________

2) 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? ____________________________________________
2.) Nutritional/Metabolic Pattern
Record the diet by a recall of ALL food and beverages taken over the last 24 hours. “Is that menu typical of most days?”
Describe eating habits and current appetite. Ask, “Who buys and prepares the food?” “Are your finances adequate for
food?” “Who is present at mealtime?” 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?
9) Describe your daily fluid intake.
3.) Elimination Pattern
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 and Exercise Pattern
This reflects usual daily activities. Ask, “Tell me how you spend a typical day?” Note ability to perform ADLs: independent
or needs assistance with feeding, bathing, hygiene, dressing, toileting, bed to chair transfer, walking, standing, or
climbing stairs? Any use of wheelchair, prostheses, or mobility aids? Record also leisure activities enjoyed and exercise
pattern (type, amount per day/week, method of warm-up session, method of monitoring the body’s response to
exercise).
1) 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
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.) Personal Habits
A. Tobacco
1) Do you smoke cigarettes (pipe, use chewing tobacco)? _____

2) At what age did you start smoking? _____
3) How many packs do you smoke per day? _____
4) How many years have you smoked? _____ (record number of packs smoked per day [PPD] and duration,
example: 1 PPD x 5 years)
5) Have you ever tried to quit? _____
6) How did it go? _____
B. Alcohol
1) Do you drink alcohol? _____

2) When was your last drink of alcohol? _____
3) How much did you drink that time? _____
4) Out of the last 30 days, about how many days would you say that you drank alcohol? _____
5) Have you ever had a drinking problem? _____
6) CAGE (cut down, annoyed, guilty, eye-opener) questions:
a. Have you ever thought you should cut down your drinking? _____
b. Have you ever been annoyed by criticism of your drinking? _____
c. Have you ever felt guilty about your drinking? _____
d. Do you drink in the morning? _____
* If person answers YES to 2 or more CAGE questions, suspect alcohol abuse
7) If patient answers NO to drinking alcohol:
a. What are your reasons for this decision? _____
b. Any history of alcohol treatment? _____
c. Are you involved in recovery activities? _____
d. Do you have a family member with a problem in drinking? _____
C. Street Drugs
1) Which of these drugs have you taken or are currently taking? _____ marijuana _____ cocaine _____
methampethamine (shabu) _____ barbiturates/depressants
2) How often do you take these? _____
3) Has your use affected your work or your family? _____
7.) Cognitive and Perceptual Pattern
1) Eyes and vision last examination result? _____ Do you wear glasses/contact lenses? _____ Do you experience
blurring? _____ 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 pain
affect your daily activities? ______________________________________________________________________
8.) Self-Perception Pattern
1) 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? _________________________________________________________
9.) Role-Relationship Pattern
1) Who do you live with? ___________________________________

2) Describe your family structure. _________________________________________________________________
3) Do you get along with your family? _____ with your friends? _____ with your co-workers? _____
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?
____________________________________________________________________________________________
10.) Sexuality and Reproduction Pattern
1) Is your sexual relationship satisfying? _____ Have any changes or problems taken place with these relationships?
_____
2) 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: ________________________________________
8) Are you currently pregnant? _____
9) Do you perform testicular examination? _____
10) Do you have prostate problems? _____ if YES, describe your complaints: ________________________________
11) Have you ever had infections of the reproductive tract? _____ if YES, what are they? ____________________
11.) Coping and Stress Management Pattern
1) What major changes/losses have you experienced in the past year? ___________________________________
2) 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. ________________________________________
12.) Value and Belief Pattern
1) 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 or
the 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?

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JOSE RIZAL MEMORIAL STATE UNIVERSITY | COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

GORDON’S FUNCTIONAL HEALTH PATTERNS

Name: _____________________________ Area: _______________ Date: ___________________

I. HEALTH PERCEPTION/HEALTH MANAGEMENT PATTERN

II. NUTRITIONAL/METABOLIC PATTERN

III. ELIMINATION PATTERN

IV. ACTIVITY/EXERCISE PATTERN

VI. PERSONAL HABITS

VII. COGNITIVE/PERCEPTUAL PATTERN

VIII. SELF-PERCEPTION PATTERN

X.COPING/STRESS MANAGEMENT PATTERN

XI. VALUES/BELIEF PATTERN

Date Received: __________________ Date Returned: ___________________

Instructor: _____________________ Student’s Name: __________________

Signature: ______________________ Signature: _______________________

GORDON’S ASSESSMENT GUIDE QUESTIONS

1) Reason for admission: ________________________________________________________________________

2.) Nutritional/Metabolic Pattern

1) How is your appetite?

3.) Elimination Pattern

1) What is your regular bowel movement pattern?

4.) Activity and Exercise Pattern

1) Describe a typical day’s activity.

5.) Sleep/Rest Pattern

1) Do you smoke cigarettes (pipe, use chewing tobacco)? _____

1) Do you drink alcohol? _____

7.) Cognitive and Perceptual Pattern

8.) Self-Perception Pattern

1) How do you feel about yourself most of the time? __________________________________________________

9.) Role-Relationship Pattern

1) Who do you live with? ___________________________________

10.) Sexuality and Reproduction Pattern

11.) Coping and Stress Management Pattern

12.) Value and Belief Pattern

1) What are the most important things to you? ________________________________________________________

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Gordon's Functional Health Pattern Format and Guide Questions

Gordon's Functional Health Pattern Format and Guide Questions

Name: _____________________ Area: _ Date: _____________

Date Received: Date Returned: _

Instructor: ___ Student’s Name:

Signature: Signature: _