DEMOGRAPHIC PROFILE ●​ “Were all your pregnancies carried to full term?

”​
​
Name: ​ ​ ​ ​
Sex:​ ​ ​ ​ ​
Age: ​ ​ ​ ​ ​
Birthdate: ​ ​ ​ Pregnancy Outcomes
Place of Birth: ​ ​
Marital Status: ​ ​ ​ ●​ “How were your deliveries—normal delivery or cesarean section?”​
Nationality: ​ ​ ​ ​
Religion: ​ ​ ​ ●​ “Did you experience any complications during pregnancy or delivery?”​
Phone number:​ ​ ​
Contact Person: ​ ​
Contact Number: ​ ​ 🔎 Follow-up if needed:
Educational Background: ​ ​
●​ “Were there any miscarriages or pregnancies that did not reach full term?”​
Occupation: ​ ​ ​ ​
Health insurance:​​ ​
●​ “Did any of your babies need special care after birth?”​
Source and reliability: ​

REASON FOR SEEKING HEALTHCARE/CHIEF COMPLAINT: ​

Chief Complaint:​​ ​
Pregnancy-Related Conditions
Admitting Diagnosis:
●​ “During any of your pregnancies, were you diagnosed with high blood
pressure or diabetes?”​
Admitting Vital Signs

●​ “Do you recall being told you had gestational hypertension or

●​ Temp:
preeclampsia?”
●​ HR:
●​ RR:
●​ BP:
●​ O₂ Sat:
Fertility History
●​ GCS:
●​ “Did you ever experience difficulty getting pregnant?”​
Gravida–Para

●​ “How many times have you been pregnant in your lifetime?”​ ●​ “Were you ever evaluated or treated for infertility?”​

●​ “How many children do you have?”​

Sexual History (ask gently)

●​ “Are you currently sexually active?”​ Menstrual Symptoms

●​ “Is it with one partner?”​ ●​ “Do you usually experience pain or cramps during menstruation?”​

●​ “Do you have any concerns related to sexual activity at this time?”​ ●​ “Have you ever noticed heavy bleeding, spotting between periods, or
bleeding after intercourse?”​

➡️ Acceptable if patient answers: “Not a priority right now”

Last Menstrual Period

●​ “When was your last menstrual period?”​

Contraceptive History

●​ “Have you used any family planning or birth control methods in the past?”​

●​ “What type did you use and for how long?”​ Gynecologic Conditions

●​ “Are you currently using any contraceptive method?”​ ●​ “Have you ever been diagnosed with any gynecologic conditions or
infections?”​

🔎 Probe if needed: ●​ “Have you ever had sexually transmitted infections or pelvic infections?”​

●​ “Did you stop using contraception for any particular reason?”

Gynecologic Procedures
GYNECOLOGIC HISTORY
●​ “Have you ever had any gynecologic surgeries or procedures, such as D&C
Menstrual History or hysterectomy?”​

●​ “At what age did you have your first menstruation?”​

●​ “How would you describe your menstrual cycle—regular or irregular?”​

Cervical Screening
●​ “How many days does your period usually last?”​
●​ “Have you ever had a Pap smear?”​
●​ “Is the flow light, moderate, or heavy?”​
 ●​ “When was your most recent Pap smear?”​ ●​ “Do you know what medications she is taking for her heart condition?”​

●​ “Do you recall if the result was normal?”​

Vaginal Health Paternal Side

●​ “Have you noticed any vaginal discharge, foul odor, itching, or discomfort ●​ “How about on your father’s side—any known chronic illnesses?”​
before your admission?”
●​ “Any history of hypertension, diabetes, heart disease, or stroke on your
father’s side?”​

Breast Health
PAST HEALTH HISTORY:
●​ “Do you perform breast self-exams?”​
1.​ Childhood Illnesses
●​ “Have you noticed any breast lumps, pain, or nipple discharge?”​ ●​ “When you were a child, did you have any serious illnesses?”​

●​ “Have you ever had a mammogram?” ●​ “Did you have illnesses like measles, chickenpox, or asthma growing up?”​

●​ “Were there any long hospital stays during your childhood?”​

General Family History

➡️ If none: “No significant childhood illnesses reported.”
●​ “Are there any illnesses that run in your family?”​
2. Hospitalizations and Surgeries
●​ “Has any close family member been diagnosed with heart disease, high
blood pressure, diabetes, or stroke?”​ ●​ “Have you ever been admitted to the hospital before this?”​

●​ “Have you ever had any surgeries or operations?”​

Maternal Side 🔎 Probe:

●​ “How about on your mother’s side—did your mother or her relatives have ●​ “Any minor procedures, even many years ago?”​
any heart problems?”​

●​ “Was your mother ever diagnosed with heart disease or chest pain?”​ ➡️ If none: “No previous hospitalizations or surgeries.”
3. Serious Injuries ●​ “Have you received the COVID-19 vaccine?”​

●​ “Have you ever had any serious accidents or injuries?”​ ●​ “How many doses and do you recall the brand?”​

●​ “Any head injury, fractures, or loss of consciousness in the past?”​

➡️ If none: “No history of serious injuries.” 6. Allergies

●​ “Do you have any allergies to food, medicines, or the environment?”​

4. Serious / Chronic Illnesses ●​ “Have you ever experienced rashes, difficulty breathing, or swelling after
taking medications?”​
●​ “Have you ever been diagnosed with any long-term illness?”​

●​ “Do you have high blood pressure, diabetes, heart disease, or seizures?”​ ➡️ If none: “No known drug, food, or environmental allergies.”
●​ “When were you first told you had high blood pressure or diabetes?”​
7. Maintenance Medications (Home Meds)

🔎 Probe: ●​ “Before hospitalization, what medicines were you taking regularly?”​

●​ “How often do you take them?”​

●​ “Are you on maintenance medications for these conditions?”​

●​ “Do you sometimes miss doses? What makes it difficult?”​

●​ “Do you have regular checkups?”​

5. Immunization History
🔎 Probe:
●​ “Do you take medicines only when you feel symptoms?”
●​ “Do you recall receiving your childhood vaccinations?”​
8. Travel History
●​ “Do you have a BCG scar?”​
●​ “Have you traveled outside your city or country recently?”​
●​ “Have you received vaccines like measles, tetanus, or hepatitis B?”​
●​ “Any travel in the past few months before you got sick?”

COVID-19
GORDON’S FUNCTIONAL HEALTH PATTERN 3. Elimination Pattern

1. Health Perception–Health Management Pattern ●​ “Before admission, how often did you usually urinate and have bowel
movements?”​
●​ “Before you were hospitalized, how did you usually describe your health?”​
●​ “Did you ever experience constipation before?”​
●​ “What do you think caused your current condition?”​
●​ “Since being hospitalized, have you noticed changes in bowel movement?”​
●​ “How were you managing your high blood pressure and diabetes before?”​
●​ “Do you feel discomfort with the catheter or difficulty voiding?”​
●​ “Were there times you missed or stopped taking your medications? What
made it difficult?”​

●​ “When you feel symptoms like headache or dizziness, what do you usually
do?”​ 4. Activity–Exercise Pattern

●​ “Do you use any herbal medicines or home remedies?”​ ●​ “What activities were you able to do on your own before you got sick?”​

●​ “How did you usually exercise or stay active?”​

●​ “Now, what movements are difficult for you?”​

2. Nutritional–Metabolic Pattern
●​ “Do you feel weak or easily tired when moving or being repositioned?”​
●​ “Before hospitalization, what was your usual diet like?”​
●​ “What worries you most when trying to move?”​
●​ “Do you usually eat on time or skip meals?”​

●​ “How much water do you drink in a day?”​

●​ “Were there any foods you avoided because of your blood pressure or 5. Sleep–Rest Pattern
sugar?”​
●​ “How many hours of sleep do you usually get at night?”​
●​ “Do you feel any difficulty swallowing now?”​
●​ “Do you feel rested when you wake up?”​
●​ “Have you noticed weight loss or poor appetite recently?”​
●​ “Since being in the hospital, is it hard to sleep?”​

●​ “What usually helps you relax or sleep?”​

 ●​ “Is this something you would like to discuss later when you feel better?”​

6. Cognitive–Perceptual Pattern

●​ “Do you feel alert and aware of what’s happening around you?”​
10. Coping–Stress Tolerance Pattern
●​ “Do you have headaches or pain right now?”​
●​ “What worries you most about your condition right now?”​
●​ “Is it difficult for you to speak or express what you want to say?”​
●​ “How do you usually cope with stress?”​
●​ “Do you feel numbness or changes in sensation on one side of your body?”​
●​ “Who do you talk to when you feel anxious or afraid?”​

7. Self-Perception–Self-Concept Pattern ●​ “What helps you stay hopeful?”​

●​ “How do you feel about yourself now compared to before your illness?”​

●​ “What has been the hardest part of this experience for you?”​
11. Value–Belief Pattern
●​ “Do you feel frustrated or worried about being dependent on others?”​
●​ “Is your faith or belief system important to you during this illness?”​

●​ “Does praying or spiritual practice help you cope?”​

8. Role–Relationship Pattern ●​ “Is there anything we can do to support your spiritual needs?”​

●​ “Who usually takes care of you at home?”​

●​ “How has your illness affected your role in the family?”​

●​ “Who do you rely on most for emotional support?”​

9. Sexuality–Reproductive Pattern

●​ “Do you have any concerns related to intimacy or your relationship at this
time?”​