GORDONS FUNCTIONAL ASSESSTMENT HISTORY TAKING

I.

Demographic Data (Biographical Data): Clients Name: Abanilla, Ramon Age: 50 Marital Status: single Religion: Catholic Address: #31 2nd st., Las Pinas Village, Pamplona III Las Pinas City Telephone Number/Cell Phone Number: 846-91-57 Birth Date and Place: San Juan De Dios Hospitality Pasay City Race / Nationality: Filipino Usual Source of Medical Care: Hospitals, sometimes clinic Source of Reliability of Information: Doctors

II. III.

Reasons for Seeking Health Care: Due to sickness and illness. History: A. Medical History of Past Health a. Pediatric / childhood / adult illness - Convulsion - High fever - cough with bacteria b. Injuries or accidents - none c. Hospitalization and operations - Dengue when he is a child - operation in his tonsils d. Obstetric history (for female clients only) e. Immunizations : Complete Dose

IV.

Functional Assessment ( narrative presentation )

1. Health perception/health management pattern ( describes clients perceived patterns of health and well being and how his health is managed ) How would you describe your health overall? I think my overall health is not so fine but not so weak because sometimes I can easily absorbs the bacteria and the heat of the environment How would you describe your health at this time? My health at this time is very ok and it is because of my nurse.

2. Self-esteem, self concept, self perception pattern ( describes how persons perceive themselves, their capabilities, body image and feelings ) How would you describe yourself? Me I will just say that I am a simple person all I want is make fun and I want that my love one is to be happy too. Do you frequently have feelings of anger? Anxiety? Depression? Fearfulness? If so, describe. Yes, because I am just a human and I am not perfect thats why I felt sometimes anger and depression

3. Activity/exercise pattern ( describes pattern of exercise, activity leisure and recreation, includes of daily living, type and quality of exercise and factors affecting activity pattern ) Do you exercise? If so, describe the type, frequency, intensity, and duration of exercise? Yes I have daily exercise in the morning I go jogging in our village. Do you experience any problems associated with sleeping, such as difficulty falling sleep, difficulty remaining asleep, or early awakening? If so describe. Maybe I have difficulty in sleeping but sometimes I can easily sleep but there is also a time that when 3 am in the morning I get easily wake up and difficulty in sleep back again.

4. Nutritional-metabolic pattern ( describes consumptions relative to metabolic need and nutrient supply; includes pattern of food and fluid consumption, condition of skin hair, nails and mucous membrane, body temperature, height and weight ) When you have wound, do heal quickly? Yes sometimes I have wounds and it is easily to heal. Describe what you usually eat. Breakfast? Lunch? Dinner? Snacks? I usually eat all that because I need to have more and more strength nd nutrition to have a healthy body,

5. Elimination pattern ( describes patterns of excretory function bowel, bladder and skin; includes individuals daily pattern, changes and disturbances )

6. Sleep rest pattern ( describe pattern of sleep, rest and relaxation ) - How many hours per night do you generally sleep? I slept around 8 or 9 pm I think I had 11hours of sleep.. - Do you generally feel rested after sleep? Yes I definitely feel that I am rested.

7. Cognitive-perceptual pattern ( describes sensory perceptual and cognitive patterns; include adequacy modes; vision, hearing, touch, taste, and smell; reports of pain perception and cognitive functional abilities ) - Are you able to read and write? Of course I can read and write - Do you experience pain? If so, describe. Yes I do experience that pain in to ways 1st in emotional 2nd is physical. 8. Role Relationship Pattern ( describes pattern of role engagements and relationship; includes perception of major roles and responsibilities in current life situation ) - When there is a conflict in your family, how is it resolved? It is resolved by talking and understanding the problem. - Do you have a significant with each other? If yes, is this relationship satisfying. Definitely we have a significant and its satisfies me 9. Sexuality Reproductive Pattern ( describes patterns of satisfaction or dissatisfaction with sexuality; includes female reproductive state ) - Are you sexually active? If yes, how many partners do you have? No Im not sexually active because Im too young for that. 10. Coping Stress Tolerance Pattern ( describes general coping pattern and effectiveness of coping skills in stress tolerance ) - Do you use medication, drugs, or alcohol to help you relax? If yes describe. No I dont have - Have there been any major changes in your life within the last couple of years? If so, describe. Yes 1st is my emotional life next is my social life. 11. Value Belief Pattern (describes patterns of value, goals or beliefs that guide lifestyle choices and decisions) - Do you have any plans or goals for the future? Yes I have many plans and goals - Do you generally get what you want out life? Sometimes I get sometimes I cant but I am contented on what I have right now.