St.
Paul University Philippines
Tuguegarao City, Cagayan 3500
SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES
COLLEGE OF NURSING
1ST SEMESTER, AY 2019-2020
BACHELOR OF SCIENCE IN NURSING – LEVEL II
Questionnaire
QUESTIONS FOR A-D (Part 2)
A. BIOGRAPHICAL DATA
Name:
Address:
Gender:
Birthdate:
Place of Birth:
Race or Ethnic Background:
Primary or Secondary Languages:
Marital Status:
Religious Practices:
Educational Level:
Occupation:
Significant other or support persons: (availability)
A.2. LIFESTYLE AND HABITS
1. Description of a typical day (am to pm)
2. What is the nutrition and weight management 24-hour dietary intake
3. Who purchases and prepares meals
4. What is/are the activities on a typical day
5. What is/are the exercise habits and patterns
6. What is/are the Sleep and rest habits and patterns
7. Use of medication
a. Are you on maintenance?
b. What vitamins and other supplements do you take and how much?
8. Use of other substances (caffeine, alcohol, recreational drugs)
a. How much beer, wine or other alcohol do you drink on average?
b. How much caffeinated drinks (coffee or tea) do you drink on average?
c. Any experience of recreational drugs?
9. Self-concept
a. How do you feel about yourself and your appearance?
b. What do you do to feel good about yourself?
10. Self-care responsibilities
11. What are his/her social activities for fun and relaxation
12. What are his/her activities contributing to society
13. Relationships with family, significant others, and pets
a. Who is/are the most important person(s) in your life?
b. What is the relationship life with your spouse?
c. What is your relationship like with your children?
d. Do you have any pets?
14. Values and spirituality
a. Do you have a religious affiliation? Is this important to you?
15. Types of work and level of job satisfaction
16. Work stressors
17. Stressors in life
18. Coping strategies (both work and life)
19. Residency and type of environment
20. Neighborhood and environmental risks
B. CLIENT’S CHIEF COMPLAINT
What problems have you been having?
What's been troubling you?
And then for further assessment, we could make use of the COLDSPA again
Character
o How does it feel, look, smell, sound, etc.?
Onset
o When did it begin;
o Is it better or worse, or the same since it began?
Location
o Where is it located?
Duration
o How long does it last?
o Does it reoccur?
Severity
o How bad is it on a scale of 1-10
Pattern
o What makes it better?
o What makes it worse?
Associated Factors
o What other symptoms do you have with it?
o Will you be able to continue doing your work or other activities (i.e daily leisure or exercise)
C. HISTORY OF PRESENT HEALTH CONCERN (COLDSPA)
Character
o How does it feel, look, smell, sound, etc.?
Onset
o When did it begin;
o Is it better or worse, or the same since it began?
Location
o Where is it located?
Duration
o How long does it last?
o Does it reoccur?
Severity
o How bad is it on a scale of 1-10
Pattern
o What makes it better?
o What makes it worse?
Associated Factors
o What other symptoms do you have with it?
o Will you be able to continue doing your work or other activities (i.e daily leisure or exercise)
D. PAST MEDICAL HISTORY
1. Was there any Problems at birth?
2. Was there any Childhood Illnesses?
3. Immunization to date
4. Any experience of surgeries
5. Any experience of accident?
6. Prolonged pain or pain patterns
7. Any allergies
8. Physical, emotional, social or spiritual weaknesses and strengths
QUESTIONS FOR E-F
E. FAMILY HEALTH HISTORY
1. Family Health History
2. Age of parents if still alive (date of death)
3. Parent's illnesses
4. Grandparent's illnesses
5. Aunts and uncles' ages
6. Illnesses Children's ages and illnesses or handicaps
F. REVIEW OF SYSTEMS
CONSTITUTIONAL: GASTROINTESTINAL: NEUROLOGICAL:
No problems No problems No problems
Abnormal Weight Gain Abdominal pain Frequent headaches
Abnormal Weight Loss Constipation Fainting
Fatigue Nausea Weakness
Weakness Vomiting Change in sensation
Fever Diarrhea Problems with walking/balance
Chills Heart burn Dizziness
Loss of Appetite Vomiting blood Tremor
EYES: Black/tarry stools Loss of consciousness
No problems Jaundice Uncontrolled movements
Vision Problems Pain with swallowing Numbness
Blurred Vision Change in bowel PSYCHIATRIC:
movements/habits
Double Vision GENITOURINARY: No problems
Wear glasses/contacts No problems Disorientation/confusion
Pain Painful urination Insomnia
Redness Frequent urination Irritability
Excessive tearing Incontinence (loss of bladder Nervousness
control)
Dry eyes Bladder problems Anxiousness
Last eye exam Menopause Hallucinations
EARS, NOSE, MOUTH & MUSCOSKELETAL: Impaired recent memory
THROAT:
No problems No problems Impaired remote memory
Difficulty with hearing Joint pain Compulsions
Ringing in ears Aching muscles ENDOCRINE:
Ear pain Shoulder pain No problems
Discharge from ears Swelling of joints Intolerance to heat or cold
Nasal Congestion Joint deformities Excessive urination
Bloody noses Back pain Excessive thirst/hunger
Sinus problems INTEGUMENTARY: Excessive sweating
Runny nose No problems HEMATOLOGIC/LYMPHATIC:
Sore tongue Rashes No problems
Sore throat Itching Easy bleeding
Hoarse voice Skin lesions Easy bruising
Mouth lesions Discoloration of some skin Anemia
area
Loose teeth/wear dentures Hair loss or increase in skin Unexplained swollen areas
hair
CARDIOVASCULAR: Abnormal size of moles Enlarged lymph nodes
No problems Nail bed color changes ALLERGIC/IMMUNOLOGIC:
Irregular heartbeat Breast pain No problems
Abnormal heart sounds Breast lumps Seasonal allergies
Chest pain/pressure Nipple discharge Sneezing
Pain when walking Recurrent infections
Swelling of feet and legs
RESPIRATORY:
No problems
Wheezing
Coughing
Shortness of breath when moving
Shortness of breath when resting
Prolonged cough
Coughing up blood
Production of phlegm
Painful breathing
G. GORDON’S 11 FUNCTIONAL HEALTH PATTERNS
I. HEALTH PERCEPTION AND HEALTH MANAGEMENT
1. When is your last physical examination or check up and do you often visit your physician for check-ups or
just when needed?
2. History of Hospitalization
3. History of illness in the family
4. Are you immunized?
5. Do you have past illness?
6. Do you have any allergies? If there is any, what do you do to prevent them?
7. Do you have any past surgeries? If yes, what type of surgery it?
8. Any vices like drinking alcohol? Smoking?
9. How often? How many sticks or how many bottles in a week or in a month?
10. when did the last time you drink alcohol or smoke cigarettes?
11. How’s your health recently and now?
II. NUTRITIONAL-METABOLIC
1. Usual food intake
2. Usual fluid intake (type and amount)
3. Water
a. How many glasses per day?
b. Coffee (How many cups per day?)
c. What other drinks you usually drink?
4. Any food restriction regarding your religious or disease point of view?
5. Problems with ability to eat?
6. Any supplements you take?
7. Describe your appetite (good or bad?)
8. Is your eating habit affected when you’re stressed? Also, in what other way?
9. Lately, have you notice that you are gaining weight or losing weight?
10. What amount have you lose or gain?
11. When you are sick, do you recover quickly or for a long time?
12. Any skin problem?
13. Any dental problem?
III. ELIMINATION
1. During passing defecation?
2. Do you have any difficulty or discomfort?
3. Your urinary elimination patterns and bowel movement?
a. Frequency, discomfort, problem
b. Color of stool and urine
4. Other problems
IV. ACTIVITY AND EXERCISE
1. Do you exercise?
2. What type of exercise are you doing?
3. How often do you do it?
4. Do you have any breathing problem while doing exercises and activities?
5. May history ba ng dyspnea or fatigue?
6. How do you spend your spare time? Is it for your hobbies? Or sports
7. Ano yung mga ginagawa mo para maging productive?
8. Affected ba yung productivity mo kapag may problema ka or stressed? In what way?
9. Sa tingin mo, enough ba or sufficient yung energy mo para sa everyday activities na kailangan mong gawin?
10. Saan mo madalas nailalaan yung time mo sa araw araw?
V. SLEEP AND REST
1. Usual sleep pattern?
2. Do you at least complete the normal sleeping hours which is 6-8 hours?
3. Problems with sleep?
a. Well rested ba pagkagising?
b. Nahihirapan ba matulog?
c. Nahihirapan ba gumising?
d. May iniinom bang gamot pampatulog?
e. May sleep interruptions ba?
4. Are you using any medication for sleeping?
5. What do you feel when waking up?
6. Fresh, headache, drowsy
7. Rest and relaxation periods
VI. COGNITION AND PERCEPTION
1. Hearing - describe
2. Sight - describe
3. Touch - describe
4. Read and write?
5. Leaning?
6. Any other complaints aside from sight, hearing, touch, read write and learning?
7. Any assistive devices do use like hearing aid? Eyeglasses?
8. Do you easily forgot what you memorize in some instances?
9. Are you having are you having a difficulty in constructing a sentences or arguments?
VII. SELF PERCEPTION AND SELF-CONCEPT
1. How do you feel about yourself most of the time?
2. What is the thing that you most love about yourself?
3. Are you satisfied about your self-body image?
VIII. ROLES AND RELATIONSHIPS
1. What is your role in your family, workplace and school?
2. Significant persons or important persons for the client?
3. Inside your family, whose decision do you follow?
4. Complaints or conflicts in your family members or is it a significant person.
5. Did you experience difficulties in your role? Why?
6. What do you think is the best way for you to fulfill it?
a. Are there any obstacles for you to fulfill it properly?
7. How is your relationship with them?
a. Do you feel happy or lonely with them?
IX. SEXUALITY AND REPRODUCTION
1. Do you have any sexual problem?
2. Do you do active or passive sex?
X. COPING AND STRESS TOLERANCE
1. Ano yung madalas na nagiging problema or cause ng stress mo? Bakit?
2. Sino yung support system mo pag may problema ka or pag stressed?
3. Pano ka natutulungan ng support system mo?
4. Anong ginagawa mo madalas pag may problema or pano mo namamanage yung stress mo?
5. Sa tingin mo effective ba yung way mo ng pagmamanage sa stress mo?
6. May tinatake ka bang mga gamot pag stressed ka? Or any home remedies?
7. Have you experienced any crisis?
8. How did you manage?
XI. VALUES AND BELIEFS
1. What is your religion?
2. What is the unique characteristic of your religion that you could be proud of?
3. Do you often pray or worship?
4. Where or to whom do you take courage?
5. How important is religion in your life?
6. How does it help you face your problems?
7. What are your religious practices?
8. How often do you perform your religious practices?
9. What is your life motto?
10. What are your plans in life? Or the things that you want to achieve?
