A.

Patient’s Profile
What is your Name? (Ano tim ngaran?):
How Old Are You? (Pira na time edad?):
Gender:
When is your Birthday? (Kakan.o ka gin anak?):
Where were you born? (Diin ka gin anak?):
Where do you live? (Hain ka naukoy?):
Are you married? (May asawa ka na?):
Do you have Children? (Mayda mo mga anak?)
No. of Children (Pira na it iyo anak?)
Do you have Siblings? (Mayda ka mga bugto?)
No. of Siblings (Pira man kamo mag burugto?)
Order Among Siblings (Ika – pira ka man ha iyo mag burugto)
Name of Parents (Ngaran hit kag – anak)

Mother (Ano ngaran hit iyo Nanay?)

Occupation (Ano man trabaho imo Nanay?)
Contact No. (Pwede ako umaro iya contact number?)

Father (Ano ngaran hit iyoTatay?)

Occupation (Ano man trabaho imo Tatay?)
Contact No. (Pwede ako umaro iya contact number?)

Educational Background (Ano man an imo natapos?)

Occupation (Ano man it imo trabaho yana?)
Nationality (Ano tim nasyonalidad?)
Religion (Ano tim relihiyon?)
Contact No. (Pwede ako umaro imo contact number?)

ICE (In Case of Emergency):

Name:
Contact No.:
Relationship:

B. History of Present Illness

How are you feeling today? (Ano tim inaabat yana?)
How long has the problem been an issue? (Kakan.o pa ini nagtikang?)
Is the problem worse in the morning or evening, or is it constant? (It imo inaabat, mas
nagrabe ha aga? Ha gab.i? Kun aga tutob gab.i, malain talaga tim inaabat?)
Is it connected to the activities you did in the past few days? (Konektado ini han imo mga
gin himo nga aktibidades han nag labay nga mga adlaw?)
Have you taken any medications? Is it prescribed by the doctor? (May gin tutumar ka yana
nga mga medisina? Gin resita ini han doktor?)
If you had any medications taken, did your condition lessen, or did it become worse? (Kun
mayda ka gin tumar, umupay nim inaabat? Kun naglain duroy nim inaabat?)
If you didn’t have any medications taken, what did you do to improve your condition?
(Kun waray ka gin tumar, ano man nim gin himo para umupay nim inaabat?)
(If you had any medications taken), did the medications help? (Nakabulig an imo pag
tumar?)
(If you didn’t have any medications taken), did the things you do help to improve your
condition? (Nakabulig an imo mga gin himo para umupay nim inaabat?)

C. Medical History
Have you ever been admitted to a hospital? (Na admit ka na han una?)
If you have been admitted, when was the time you were recently admitted? (Kun na admit
ka na, kakan.o an imo last nga pag pa admit?)
Do you have any allergies? (Mayda ka mga allergy?)
If you have allergies, what are these allergies? (Kun mayda ka mga allergy, ano man ini nga mga
pagkaon?)
Have you taken any medications to lessen the allergies? Is it prescribed by the doctor?
(May gin tumar ka nga mga medisina para maibanan an imo allergies? Gin resita ini han
doktor?)
If you had any medications taken, did your condition lessen, or did it become worse? (Kun
tumumar ka na, umupay nim gin abat? Kun naglain duroy nim inaabat?)
If you didn’t have any medications taken, what did you do to improve your condition?
(Kun waray ka pa gin tumar, ano man nim gin himo para umupay nim inaabat?)
Did the medications help? (Nakabulig an mga medisina?)
(If you didn’t have any medications taken), did the things you do help to improve your
condition? (Nakabulig an imo mga gin himo para umupay nim inaabat?)
Have you any had vaccinations before? (Nag pa vaccine ka na han una?)
If yes, what are these vaccinations? (Kun oo, ano man ini nga mga vaccine?)

D. Family History

Do you have other siblings? (Mayda ka iba nga bugto?):

If yes, how many siblings do you have? (Kun mayda, pira pa man it im bugto?):
What is your order among the siblings? (Ika pira ka ha iyo magburugto?):
Have you ever lived away from your parents? (Bumulag ka na ba ha imo kag – anak?):
If yes, explain why. (Kun oo, ibutang kun kay ano.?)
Is there a history of drug/alcohol problems in the family? (Mayda ba ha iyo pamilya na
gamit hin pinagbabawal nga droga, ngan naimon hin makahurbog nga irimnun?)
If yes, who and what kind of substance? (Kun oo, hin.o ha iyo pamilya ngan ano nga
substansiya an gin gamit?):
Within your family, is there someone who has asthma? (Ha iyo pamilya, mayda gin
hihika?):
 E. Psychosocial History

Do you exercise every day? (Nag ihersisyo ka adlaw – adlaw?):

If yes, what are these specific exercises? (Kun oo, ano man ini nga mga ihersisyo?):
In your work or in school, do you participate in sports? (Ha imo trabaho o ha skwelahan,
na api ka hin sports?):
If yes, what sports are these? (Kun oo, ano man ini nga mga sports?):
Do you drink alcoholic beverages? (Parag inom ka?):
If yes, how many glasses do you drink in a week? (Kun oo, pira man ka baso tim gin iinom
nga beer ha usa ka simana?):
Do you eat three times a day? (Nakaon ka tulo ka beses ha usa ka adlaw?):
Do you eat snacks after every meal? (Nakaon ka hin snack kada tapos mo kaon?):
How many cups of rice do you usually eat? (Pira ka tasa it imo nakakaon na kan.on?):
Do you eat fruits every after meal? (Nakaon ka hin prutas katatapos pirmi pagkaon?):
Do you eat vegetables with every meal? (Nakaon ka hin utan kada pagkakaon nim?):
Are you having a hard time defecating? (Nagkukuri ka tim pag uro?):
If yes, how seldom do you defecate? (Kun oo, kada san.o ka man la nakaka uro?):
Are you having a hard time urinating? (Nagkukuri ka tim pag ihi?):
If yes, how seldom do you urinate? (Kun oo, kada san.o ka man la nakaka ihi?):
What are your hobbies in home? (Ano man it imo pirmi libang ha balay?):
Do you do this often? (Pirmi mo ini gin hihimo?)

Gordon’s Typology Functional Health Assessment

1. Health Perception and Health Management Patterns

In general, how is the family’s health? (Ha kabug.usan, kamusta man it kalusugan hit
pamilya?):
What do you do to stay healthy? (Nag aano ka man para maging healthy ka la gihap?):
Do you drink alcohol? (Nainom ka hin makahurubog nga irimnun?):
Do you smoke? (Na sigarilyo ka?):
If yes, how may sticks of cigarette do you consume a day?: (Pira man ka stick hit sigarilyo
it imo nauubos?)
Do you have regular check-up with your physician and/or specialists (Pediatrician,
Ob/Gyn, Cardiologist, etc.) (Regular ka napacheck – up ka ha imo doktor?):
If yes, when do you see a doctor for a check – up? (Kun oo, kada san.o ka man napacheck –
up ha imo doktor?):

2. Nutrition and Metabolism

Describe your Family’s typical daily food intake? (????):
Do you consider your family healthy eaters? (Para ha imo, healthy kamo nga nangangon?):
Describe your family’s typical daily fluid intake? (Pira ka baso nga tubig it iyo naiinom ha
kada adlaw?):
Does anyone consider themself over or under weight? (Mayda ha iyo pamilya nga nag
huhuna huna nga matambok o magasa hiya?):
Is there any unexplained weight gain or loss? (Mayda mga panahon nga tumigda nala na
pag tambok o pag – gasa?):