GUIDE QUESTIONS FOR ASSESSMENT

B. PRESENT HEALTH HISTORY

A. PATIENT’S PROFILE
1. What is the most urgent health concern?
1. Name
3. What were the immunizations had?

2. When did it start? What was it like?

2. Birthday

3. Has the problem changed at all? If so, when and in

3. Age what way? 4. Did you undergo surgeries and/or operations? If
yes, on what specific part or reason?

4. Place of birth 4. Has medical attention been sought before now? If

so, what investigations have been done so far?
What treatments have been tried?
5. Present address 5. How about accidents? If yes, what happened?

6. Any siblings? If yes, what is his or her birth order 5. Were there any previous episodes?
among them? 6. Any allergies?
Ask the name, birthday, and age.
6. What are its relieving or aggravating factors?

C. PAST HEALTH HISTORY

7. Religion 1. Past health illnesses? If yes, what was it / what
were they?
7. Any medications?
8. Names of parents and their occupation
Ask if parents are married. 2. Has been hospitalized? If yes, what was the cause?
When did it happen? Name of the hospital? Name
of the doctor?
9. Educational level
 3. Housing Choosing which symptoms to ask about depends on the
D. FAMILY HEALTH HISTORY presenting complaint and your level of experience.
1. Age of parents

a. Head – History of injury, headaches or infection?

4. Parental/Guardian’s smoking status

2. Can you remember any illnesses from your parents
or relatives? How old are they? What is the
longevity of the illness? b. Eyes – Visual acuity/glasses? History of injury,
headaches or surgery?
5. Relationships/marital status

3. Illnesses or diseases from maternal side? Paternal

side?
6. Preferred leisure activities? Are you happy
at home?
4. Deaths in the family – cause and age, especially if
in infancy or childhood

c. Nervous system – Fits, faints, or funny turns?

History of hearing concerns, seizures (febrile or
afebrile), abnormal or impaired movements,
tremors or change in behaviour? School
7. Impact of this illness on the family (especially if performance? History of hyperactivity?
E. PSYCHOSOCIAL LIFESTYLE AND PRACTICES chronic or ongoing)?
1. Individuals living with?

d. ENT – Earache, throat infections, snoring or noisy

breathing (stridor)?
REVIEW OF SYSTEMS
2. Parental/Guardian’s occupation
This may pick up on symptoms the parents or guardians the
child failed to mention in the presenting complaint and
some of these symptoms may be relevant to the diagnosis.
e. Chest – Cough, wheeze, breathing k. Pubertal development – Age of menarche?
problems? Smokers in the family? Exposure to • Who do you get on with best and/or fight with
smoke? most?

OTHER KEY QUESTIONS:

• Vomiting – Determine frequency, volume and • Who do you turn to when you’re feeling down?
consistency (e.g. bilious, haematemesis). Also,
f. Heart – Cyanosis, exercise tolerance, chest pain, clarify if it was projectile vomiting.
fainting episodes? History of heart murmurs or Education and employment
rheumatic fever in the child or the family? • Are you in school/college at the moment?
• Fever – Ask about readings and how they were
recorded.
• Which year are you in?

g. GIT – Vomiting, diarrhea/constipation, abdominal • Rash – Determine location and rate of spread.
pain? Rectal bleeding? • What do you like the best/least at school/college?

• Coryzal symptoms (e.g. “runny nose” “sniffly” etc)

h. Genitourinary – Dysuria, frequency, • How are you doing at school?

wetting/accidents, toilet training?
• Cough and/or increased work of breathing
• Weight change – Review growth charts if available. • What do you want to do when you finish?

i. Joints/Limbs – Gait, limb pain or swelling, other

functional abnormalities? • Pain – Explore using SOCRATES or COLDSPA
• Do you have friends at school?

j. Skin – General rashes? Birthmarks or unusual Home and relationships

marks? • Who lives at home with you?
• How do you get along with others at school?
• Do you have your own room?
 • Do you think about hurting or killing yourself?
• Do you work? How much? Sex and relationships
• Are you seeing anyone at the moment?
• Have you ever tried to harm yourself?

• Are they a boy or a girl?

Eating Safety and abuse
• Are you worried about your weight or body shape? • Do you feel safe at school/at home?
• Young people are often starting to develop
intimate relationships? How have you handled
• Have you noticed any change in your weight that part of your relationship?
recently? • Is anyone harming you?

• Have you ever had sex?

• Have you been on a diet? Do you mind telling me,
how? • Is anyone making you do things that you don’t
• What contraception do you use? want to?

Drugs, alcohol and tobacco

At this stage – reassure about confidentiality Self-harm, depression and self-image
• Does anyone smoke at home? • How is life going in general?

• Have you ever felt unsafe when you’re online or

• Lots of people your age smoke. Have you been • Are you worried about your weight? using your phone?
offered cigarettes? How many do you smoke each
day?
• What do you do when you feel stressed?

• Many people start drinking alcohol around your

age. Have you tried or been offered alcohol? How
much/how often? • Do you ever feel sad and tearful?

• Some young people use cannabis. Have you tried

it? How much/how often?
• Have you ever felt so sad that life isn’t worth
living?
• What about other drugs, such as ecstasy and
cocaine?
 GORDONS TYPOLOGY

Health Perception and Health Management

What are your practices in maintaining healthy lifestyle?/ Ano man
it imo mga gin hihimo para padayunon hit kahimtang han imo
lawas?
Kun papapilion ka 1-10, ika napulo pinaka maupay na panlawas,
para ha imo pira
Nutrition and Metabolism
What do you usually eat? Ano tim kaurog na kinakaon? Anon a
pagkaon it imo hilig? Pira ka kabeses na kaon ha usa ka adlaw? Ano
nga mga irimnon it im gin iinom? Pira ka baso tim nauubos?

Elimination
What is your urinary pattern? Estimated volume of urine?/ Kumusta
it imo pag ihi? Masukot ba o panalagsa la? Para ha imo mga pira ka
damo it imo na iihi? An imo pag uro kumusta man?
How many times do you urinate and defecate?/ Ha usa ka adlaw
nakaka pira kaman iihi o uuro?
Activity Exercise Pattern
What is your daily activity pattern? / Ano it imo gin hihimo na
aktibidades ha pan adlaw-adlaw?
Do you exercise? What type of exercise do you do? / Nag eehersisyo
ka? Ano nga ehersisyo it imo gin bubuhat?
What are your leisures or recreational activities? / Ano it imo gin
hihimo na mga pampalipas oras?
Cognitive- Perceptual Pattern
Do you have any sensory deficits? /Mayda ka problema ha imo
pagkita, panrasa, panhamot, panbati? Kun mayda ka inaabat na
maul-ol pwede mo iyakan kun gano hiya ka ul-ol ngan kun mayda ka
nakikita nga rason hini na pagsakit?
Sleep-Rest Pattern
Tell me about your sleeping patters/ Kumusta man it imo
pagkaturog?
Do you have problem falling asleep? /Mayda ka problema ha
pagkaturog?
How much do you sleep at night? / Pira ka oras it im pagkaturog ha
us aka gabi?
Do you nap during the day? /How often and how long? / Kun adlaw
nakakakaturog ka? Panalagsa b aini or pirme? Pira man ka oras?
Self Perception Pattern
How do you feel about yourself? /Kun pakianhan ta ikaw ano man it
imo mayayakan hit imo kalugaringon?
What do you see as your talents or abilities? Ano it imo talent?
How often do you have medical check ups?/ Kada sano ka man
napakadto ha doctor pagpa check up?
Role- Relationship Pattern
Who is/ are the most important people in your life
Describe your relationship with person or people/ Para ha imo hino
man pinaka importante nga tawo ha imo kinabuhi? Pwede mo ig
istorya ha akon paano it imo relasyon ha ira?
What was it like growing with your family? / Kumusta man an imo
pagtubo ha imo pamilya? Ano man an imo responsibilidad ha imo
pamilya? Mayda kamo mga hayop? Ano man ito hira?
Sexual- Reproductive Pattern
Do you have any reproductive problems? Mayda ka ba problema ha
imo reproduction o ha imo pagkalalaki o pagkababayi?
Is it okay to ask if you practice safe sex? How many times? /Pwede
ak magpakiana kun nakikipaghilawas ka pa? Kuno o pira man ka
beses?
Kakan-o nim syahan nga regla?
Kada bulan ka gin reregla o layagan ka? Kun gin reregla ka
nakakapira man ka adlaw?
Coping and Stress Tolerance Pattern
How would you describe your level of stress? / Madali ka ba ma
stress or diri? Pag na stress ka ano man it imo binubuhat?
Para ha imo ano it pinaka nakaka hatag hin stress haimo?
Ngain o kan kanay ka man nakadto kun nagkaka ada ka hin
problema?

Values and Belief Pattern

What is the most important to you in life? / Ano it pinaka
importante ha imo kinabuhi?
Do you have religious affiliation? Is it important to you? Mayda ka
gin tutuo nga relihiyon? Ano ini ka importante ha imo?
Para ha imo importante ba magkaada hin maupay nga relasyon ha
ginoo o haimo gin tutuohan?
What gives you strength or hope? / Ano man it nahatag haimo hin
kusog o paglaom?