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GORDON’S FUNCTIONAL HEALTH PATTERN ASSESSMENT TOOL No__ Yes__ Type & Frequency: ______________________________
6. Smell 18. Have you experienced any ringing in the ears: Right ear: Yes__ No___
ADMISSION ASSESSMENT a. Right nostril: Normal__ Abnormal__ Describe:__________________ Left ear: Yes__ No__
b. Left nostril: Normal__ Abnormal__ Describe:___________________ 19. Have you experienced any vertigo: Yes__ No__ How often and when?
DEMOGRAPHIC DATA Date: ______________ Time: ______________ _________________________________________________________
7. Cranial Nerves: Normal__ Abnormal__ Describe deviations:_________ 20. Do you regularly use seat belts? Yes__ No__
Name: _______________________________________________________
Date of Birth: _________________________ Age: ________ Sex: ________ _________________________________________________________ 21. For infants and children: Are car seats used regularly? Yes__ No__
8. Cerebellar Exam (Romberg, balance, gait, coordination, etc.) 22. Do you have any suggestions or requests for improving your health?
Primary significant other: ____________________ Telephone: ___________
Name of primary information source: _______________________________ Normal__ Abnormal__ Describe:______________________________ Yes__ No__ Describe: ______________________________________
_________________________________________________________ _________________________________________________________
Admitting medical diagnosis:______________________________________
9. Reflexes: Normal__ Abnormal__ Describe: ______________________ 23. Do you do (breast/testicular) self-examination? No__ Yes__
VITAL SIGNS: _________________________________________________________ How often? _______________________________________________
Temperature: ____F ____C ; oral__ rectal __ axillary __ tympanic __ 10. Any enlarged lymph nodes in the neck? No__ Yes__ Location and size:
Pulse Rate: ____bpm; radial __ apical ___; regular ___ irregular __ _________________________________________________________ NUTRITIONAL-METABOLIC PATTERN
_________________________________________________________
Respiratory Rate: ___cpm; abdominal ___ diaphragmatic ___
Blood Pressure: left arm ___ right arm___; 11. General appearance: OBJECTIVE
a. Hair: __________________________________________________ 1. Skin examination
standing__ sitting__ lying down ___
Weight: __ pounds; ___kg b. Skin: __________________________________________________ a. Warm__ Cool__ Moist__ Dry__
c. Nails: _________________________________________________ b. Lesions: No__ Yes__ Describe: _______________________________
Height: ___feet ___inches; ___meters
d. Body odor: _____________________________________________ c. Rash: No__ Yes__ Describe: _________________________________
Do you have any allergies? No__ Yes__ What?! ________________ d. Turgor: Firm__ Supple__ Dehydrated__ Fragile__
(Check reactions to medications, foods, cosmetics, insect bites, etc.) SUBJECTIVE e. Color: Pale__ Pink__ Dusky__ Cyanotic__ Jaundiced__ Mottled__
1. How would you describe your usual health status? Other____________________________________________________
Review admission CBC, urinalyses and chest-xray. Note any abnormalitites here: Good__ Fair__ Poor__ 2. Mucous Membranes
2. Are you satisfied with your usual health status? a. Mouth
________________________________________________________
_____________________________________________________________ Yes__ No__ Source of dissatisfaction: ____________________________ i. Moist__ Dry__
3. Tobacco use? No__ Yes__ Number of packs per day? _______________ ii. Lesions: No__ Yes__ Describe: __________________________
4. Alcohol use? No__ Yes__ How much and what kind? ________________ iii. Color: Pale__ Pink__
HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN 5. Street drug use? No__ Yes__ What and how much? _________________ iv. Teeth: Normal__ Abnormal__ Describe:____________________
6. Any history of chronic disease? No__ Yes__ Describe: _______________ v. Dentures: No__ Yes__ Upper__ Lower__ Partial__
OBJECTIVE ___________________________________________________________ vi. Gums: Normal__ Abnormal__ Describe:____________________
1. Mental Status (indicate assessment with a P) 7. Immunization history: Tetanus__ Pneumonia__ Influenza__ MMR__ Polio__ vii. Tongue: Normal__ Abnormal__ Describe:___________________
a. Oriented__ Disoriented__ Hepatitis B__ b. Eyes
Time: Yes__ No__; Place: Yes__ No__; Person: Yes__ No__; 8. Have you sough any health care assistance in the past year? No__ Yes__ If yes, i. Moist__ Dry__
b. Sensorium why? _________________________________________________ ii. Color of conjunctiva: Pale__ Pink__ Jaundiced__
Alert__ Drowsy__ Lethargic__ Stuporous__ Comatose__ 9. Are you currently working? No__ Yes__ How would you rate your working iii. Lesions: No__ Yes__ Describe:___________________________
Cooperative__ Combative__ Delusional__ conditions? (e.g. safety, noise, space, heating, cooling, water, ventilation)? 3. Edema
c. Memory Excellent__ Good__ Fair__ Poor__ Describe any problem a. General: No__ Yes__ Describe:_______________________________
Recent: Yes__ No__; Remote: Yes__ No__ areas:______________________________________________________ Abdominal girth: ___inches
2. Vision 10. How would you rate living conditions at home? Excellent__ Good__ Fair__ b. Periorbital: No__ Yes__ Describe:_____________________________
a. Visual acuity: Both eyes 20/___; Right 20/___; Left 20/___; Not Poor__ Describe any problem areas: ________________ c. Dependent: No__ Yes__ Describe:_____________________________
assessed___ __________________________________________________________ Ankle girth: Right:__ inches; Left__inches
b. Pupil size: Right: Normal__ Abnormal__; 11. Do you have any difficulty securing any of the following services? 4. Thyroid: Normal__ Abnormal__ Describe: _________________________
Left: Normal__ Abnormal__ Grocery store: Yes:__ No:__; Pharmacy: Yes__ No__; Health Care Facility: 5. Jugular vein distention: No__ Yes__
c. Pupil reaction: Right: Normal__ Abnormal__; Yes:__ No:__; Transporation: Yes:__ No:__; Telephone (for police, fire, 6. Gag reflex: Present__ Absent__
Left: Normal__ Abnormal__ ambulance): Yes:__ No:__; If any difficulties, note referral here: 7. Can patient move easily (turning, walking)? Yes__ No__
3. Hearing ______________________________________________________ Describe limitations: __________________________________________
a. Not assessed__ ______________________________________________________ 8. Upon admission, was patient dressed appropriately for the weather?
b. Right ear: WNL__ Impaired__ Deaf__; Left ear: WNL__ Impaired__ 12. Medications (over-the-counter and prescription) Yes__ No__ Describe: ________________________________________
Deaf__
c. Hearing aid: Yes__ No__ Name Dosage Times/Day Reason Taken as Ordered For breastfeeding mothers only:
4. Taste Yes__ No__ 9. Breast exam: Normal__ Abnormal__ Describe:______________________
a. Sweet: Normal__ Abnormal__ Describe:______________________ Yes__ No__ ___________________________________________________________
b. Sour: Normal__ Abnormal__ Describe:_______________________ Yes__ No__ 10. If mother is breastfeeding, have infant weighed. Is infant’s weight within normal
c. Tongue movement: Normal__ Abnormal__ Describe:____________ Yes__ No__ limits? Yes__ No__
d. Tongue appearance: Normal__ Abnormal__ Describe:___________
5. Touch 13. Have you followed the routine prescribed for you? SUBJECTIVE:
a. Blunt: Normal__ Abnormal__ Describe:_______________________ Yes__ No__ Why not? ______________________________________ 1. Any weight gain in the last 6 months? No__ Yes__ Amount: ___________
b. Sharp: Normal__ Abnormal__ Describe:______________________ 14. Did you think this prescribed routine was best for you? 2. Any weight loss in the last 6 months? No__ Yes__ Amount:____________
c. Light touch sensation: Normal__ Abnormal__ Describe:__________ Yes__ No__ What would be better? ____________________________ 3. How would you describe your appetite? Good__ Fair__ Poor__
d. Proprioception: Normal__ Abnormal__ Describe:________________ 15. Have you had any accidents/injuries/falls in the past year? 4. Do you have any food intolerance? No__ Yes__ Describe: ____________
e. Heat: Normal__ Abnormal__ Describe:_______________________ No__ Yes__ Describe: ______________________________________ 5. Do you have any dietary restrictions? (Check for those that are a part of a
f. Cold: Normal__ Abnormal__ Describe:________________________ 16. Have you had any problems with cuts healing? prescribed regimen as well as those that patient restricts voluntarily, for example,
g. Any numbness? No__ Yes__ Describe:_______________________ No__ Yes__ Describe: ______________________________________ to prevent flatus) No__ Yes__ Describe: ___________________
h. Any tingling? No__ Yes__ Describe:__________________________ 17. Do you exercise on a regular basis? ___________________________________________________________
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6. Describe an average day’s food intake for you (meals and snacks): _____ e. Color: Yellow__ Smokey__ Dark__ k. Tremors: No__ Yes__ Describe: ______________________________
___________________________________________________________ f. Incontinence: No__ Yes__ When? _____________________________ _________________________________________________________
___________________________________________________________ Difficulty holding voiding when urge to void develops? No__ Yes__ 4. Spinal cord injury: No__ Yes__ Level: ____________________________
7. Describe an average day’s fluid intake for you. _____________________ Have time to get to bathroom: Yes__ No__ How often does problem reaching 5. Paralysis present: No__ Yes__ Where? ___________________________
___________________________________________________________ bathroom occur? ___________________________________ 6. Developmental Assessment: Normal__ Abnormal__ Describe: _________
8. Describe food likes and dislikes. _________________________________ g. Retention: No__ Yes__ Describe: _____________________________ ___________________________________________________________
___________________________________________________________ h. Pain/burning: No__ Yes__ Describe: ___________________________
9. Would you like to: Gain weight?__ Lose weight?__ Niether__ i. Sensation of bladder spasms: No__ Yes__ When? ________________ SUBJECTIVE
10. Any problems with:
a. Nausea: No__ Yes__ Describe: _______________________________ ACTIVITY-EXERCISE PATTERN 1. Have patient rate each area of self-care on a scale of 0 to 4. (Scale has been
b. Vomiting: No__ Yes__ Describe: ______________________________ adapted by NANDA from E. Jones, et. Al., Patient Classification for Long Term
c. Swallowing: No__ Yes__ Describe: ____________________________ OBJECTIVE Care; User’s Manual. HEW Publication No. HRA-74-3107, November 1974.)
d. Chewing: No__ Yes__ Describe: ______________________________ 1. Cardiovascular 0 – Completely independent
e. Indigestion: No__ Yes__ Describe: ____________________________ a. Cyanosis: No__ Yes__ Where? _______________________________ 1 – requires use of equipment or device
11. Would you describe your usual lifestyle as: Active__ Sedate__ b. Pulses: Easily palpable? 2 – requires help from another person for assistance, supervision or teaching
Carotid: Yes__ No__; Jugular: Yes__ No__; Temporal: Yes__ No__ 3 – requires help from another person and equipment device
For breastfeeding mothers only: Radial: Yes__ No__; Femoral: Yes__ No__; Popliteal: Yes__ No__; 4 – dependent; does not participate in activity
12. Do you have any concerns about breast feeding? No__ Yes__ Describe: Postibial: Yes__ No__; Dorsalis Pedis: Yes__ No__
___________________________________________________ c. Extremities: Feeding__; Bathing/hygiene__; Dressing/grooming__; Toileting__; Ambulation__;
13. Are you having any problems with breastfeeding? No__ Yes__ Describe: i. Temperature: Cold__ Cool__ Warm__ Hot__ Care of home__; Shopping__; Meal preparation__; Laundry__; Transportation__
___________________________________________________ ii. Capillary refill: Normal__ Delayed__
iii. Color: Pink__ Pale__ Cyanotic__ Other__ Describe: __________ 2. Oxygen use at home? No__ Yes__ Describe: ______________________
ELIMINATION PATTERN ____________________________________________________ 3. How many pillows do you use to sleep on?_____
iv. Homan’s sign: No__ Yes__ 4. Do you frequently experience fatigue? No__ Yes__ Describe: _________
OBJECTIVE v. Nails: Normal__ Abnormal__ Describe: _____________________ ___________________________________________________________
1. Auscultate abdomen: vi. Hair distribution: Normal__ Abnormal__ Describe: ____________ 5. How many stairs can you climb without experiencing any difficulty (can be
a. Bowel sounds: Normal__ Increased__ Decreased__ Absent__ ____________________________________________________ individual number or number of flights)? ___________________________
2. Palpate abdomen: vii. Claudication: No__ Yes__ Describe: _______________________ 6. How far can you walk without experiencing any difficulty? _____________
a. Tender: No__ Yes__ Where?_________________________________ ____________________________________________________ 7. Has assistance at home for self-care and maintenance of home:
b. Soft: No__ Yes__; Firm: No__ Yes__ d. Heart: PMI location: ________ No__ Yes__ Who? __________ If no, would you like to have or believes needs
c. Masses: No__ Yes__ Describe: _______________________________ i. Abnormal rhythm: No__ Yes__ Describe: ___________________ assistance: No__ Yes__ With what activities? _________________
d. Distention (include distended bladder): No__ Yes__ Describe: _______ ____________________________________________________ 8. Occupation (if retired, former occupation): _________________________
_________________________________________________________ ii. Abnormal sounds: No__ Yes__ Describe: ___________________ 9. Describe you usual leisure time activities/hobbies: ___________________
e. Overflow urine when bladder palpated? Yes__ No__ ____________________________________________________ ___________________________________________________________
3. Rectal Exam: 2. Respiratory 10. Any complaints of weakness or lack of energy? No__ Yes__ Describe:
a. Sphincter tone: Describe: ____________________________________ a. Rate:__ Depth: Shallow__ Deep__ Abdominal__ Diaphragmatic__ ___________________________________________________
b. Hemorrhoids: No__ Yes__ Describe: ___________________________ b. Have patient cough. Any sputum? No__ Yes__ Describe: ___________ 11. Any difficulties in maintaining activities of daily living? No__ Yes__ Describe:
c. Stool in rectum: No__ Yes__ Describe: _________________________ _________________________________________________________ _____________________________________________
d. Impaction: No_- Yes__ Describe:______________________________ c. Fremitus: No__ Yes__ 12. Any problems with concentration? No__ Yes__ Describe: ______
e. Occult blood: No__ Yes__ Location: ___________________________ d. Any chest excursion? No__ Yes__ Equal__ Unequal__ _____________________________________________________________
4. Ostomy present: No__ Yes__ Location: ___________________________ e. Auscultate chest:
i. Any abnormal sounds (rales, rhonchi)? No__ Yes__ Describe: __ SLEEP REST PATTERN
SUBJECTIVE ____________________________________________________
1. What is your usual frequency of bowel movements? _________________ f. Have patient walk in place for 3 minutes (if permissible): OBJECTIVE
a. Have to strain to have a bowel movement? No__ Yes__ i. Any shortness of breath after activity? No__ Yes__
b. Same time each day? No__ Yes__ ii. Any dypnea? No__ Yes__
2. Has the number of bowel movements changed in the past week? iii. BP after activity: ___/___ in (right/left) arm SUBJECTIVE
No__ Yes__ Increased?__ Decreased?__ iv. Respiratory rate after activity: _______ 1. Usual sleep habits: Hours per night ___; Naps: No__ Yes__ a.m.__ p.m.__ Feel
3. Character of stool v. Pulse rate after activity: _______ rested? Yes__ No__ Describe: ________________________
a. Consistency: Hard__ Soft__ Liquid__ 2. Any problems:
b. Color: Brown__ Black__ Yellow__ Clay-colored__ 3. Musculoskeletal a. Difficulty going to sleep? No__ Yes__
c. Bleeding with bowel movements: No__ Yes__ a. Range of motion: Normal__ Limited__ Describe: __________________ b. Awakening during night? No__ Yes__
4. History of constipation: No__ Yes__ How often? ____________________ b. Gait: Normal__ Abnormal__ Describe: __________________________ c. Early awakening? No__ Yes__
Do you use bowel movement aids (laxatives, suppositories, diet)? c. Balance: Normal__ Abnormal__ Describe: ______________________ d. Insomnia? No__ Yes__ Describe: _____________________________
No__ Yes__ Describe:_________________________________________ d. Muscle mass/strength: Normal__ Increased__ Decreased__ 3. Methods used to promote sleep: Medication: No__ Yes__ Name: _______
5. History of diarrhea: No__ Yes__ When?___________________________ Describe: ________________________________________________ Warm fluids: No__ Yes__ What? __________________; Relaxation techniques:
6. History of incontinence: No__ Yes__ Related to increased abdominal pressure e. Hand grasp: Right:: Normal__ Decreased__ No__ Yes__ Describe: _______________________________
(coughing, laughing, sneezing)? No__ Yes__ Left: Normal__ Decreased__
7. History of travel? No__ Yes__ Where?____________________________ f. Toe wiggle: Right: Normal__ Decreased__ COGNITIVE-PERCEPTUAL PATTERN
8. Usual voiding pattern: Left: Normal__ Decreased__
a. Frequency (times per day) ____ Decreased?__ Increased?__ g. Postural: Normal__ Kyphosis__ Lordosis__ OBJECTIVE
b. Change in awareness of need to void: No__ Yes__ Increased?__ h. Deformities: No__ Yes__ Describe: ____________________________ 1. Review sensory and mental status completed in health perception-health
Decreased?__ i. Missing limbs: No__ Yes__ Where? ____________________________ management pattern
c. Change in urge to void: No__ Yes__ Increased?__ Decreased?__ j. Uses mobility aids (walker, crutches, etc)? No__ Yes__ Describe: ____ 2. Any overt signs of pain? No__ Yes__ Describe: _____________________
d. Any change in amount? No__ Yes__ Increased?__ Decreased?__ _________________________________________________________
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1. Does patient live alone? Yes__ No__ With whom? __________________ 2. Are you satisfied with your sexual relationship? Yes__ No__
SUBJECTIVE 2. Is patient married? Yes__ No__ Children? No__ Yes__ Ages of Children: Describe:___________________________________________________
1. Pain ___________________________________________________________ 3. Do you believe this admission will have any impact on sexual functioning? No__
a. Location (have patient point to area) : __________________________ 3. How would you rate your parenting skills? Not applicable__ No difficulty__ Yes__ Describe: ________________________________________
b. Intensity (have patient rank on scale of 0 to 10): __________________ Average__ Some difficulty__ Describe: ___________________________
c. Radiation: No__ Yes__ To where? _____________________________ ___________________________________________________________ COPING-STRESS TOLERANCE PATTERN
d. Timing (how often: related to any specific events): ________________ 4. Any losses (physical, psychologic, social) in past year? No__ Yes__ Describe:
_________________________________________________________ ___________________________________________________ OBJECTIVE
e. Duration: _________________________________________________ 5. How is patient handling this loss at this time? ______________________ 1. Observe behavior: Are there any overt signs of stress (crying, wringing of hands,
f. What done relieve at home? __________________________________ ___________________________________________________________ clenched fists, etc)? Describe: ____________________________
g. When did pain begin? _______________________________________ 6. Do you believe this admission will result in any type of loss? No__ Yes__
2. Decision-making Describe: ___________________________________________________ SUBJECTIVE
a. Decision making is: Easy__ Moderately easy__ Moderately difficult__ 7. Ask both patient and family: Do you think this admission will cause any significant 1. Have you experienced any stressful or traumatic events in the past year in
Difficult__ changes in the patient’s usual family role? No__ Yes__ Describe: addition to this admission? No__ Yes__ Describe:___________________
b. Inclined to make decisions: Rapidly__ Slowly__ Delay__ ___________________________________________________ ___________________________________________________________
3. Knowledge level 8. How would you rate your usual social activities? Very active__ Active__ 2. How would you rate your usual handling of stress? Good__ Average__ Poor__
a. Can define what current problems is: Yes__ No__ Limited__ None__ 3. What is the primary way you deal with stress or problems? ____________
b. Can restate current therapeutic regimen: Yes__ No__ 9. How would you rate your comfort in social situations? Comfortable__ ___________________________________________________________
Uncomfortable__ 4. Have you or your family used any support or counseling groups in the past year?
SELF-PERCEPTION AND SELF-CONCEPT PATTERN 10. What activities or jobs do you like to do? Describe: ___________ No__ Yes__ Group name: ________________________________
___________________________________________________________ Was the support group helpful? Yes__ No__ Additional comments: _____
OBJECTIVE 11. What activities or jobs do you dislike doing? Describe: _________ ___________________________________________________________
1. During this assessment, does patient appear: Calm__ Anxious__ Irritable__ ___________________________________________________________ 5. What do you believe is the primary reason behind a need for this admission?
Withdrawn__ Restless__ _________________________________________________
2. Did any physiologic parameters change? Face reddened: No__ Yes__; Voice SEXUALITY-REPRODUCTIVE PATTERN 6. How soon, after first noting the symptoms, did you seek health care assistance?
volume changed: No__ Yes__ Louder__ Softer__; Voice quality changed: No__ _________________________________________________
Yes__ Quavering__ Hesitation__ Other: ______________ OBJECTIVE 7. Are you satisfied with the care you have been receiving at home? No__ Yes __
___________________________________________________________ Review admission physical exam for results of pelvic and rectal exams. If results not Comments: ___________________________________________
3. Body language observed: ______________________________________ documented, nurse should perform exams. Check history to see if admission 8. Ask primary caregiver: What is your understanding of the care that will be needed
4. is current admission going to result in a body structure or function change for the resulted from a rape. when the patient goes home? ____________________________
patient? No__ Yes__ Unsure at this time__ ___________________________________________________________
SUBJECTIVE
SUBJECTIVE Female VALUE-BELIEF PATTERN
1. What is your major concern at the current time? ____________________ 1. Date of LMP:___ Any pregnancies? Para__ Gravida__ Menopause? No__
___________________________________________________________ Yes__ Year__ OBJECTIVE
2. Do you think this admission will cause any lifestyle changes for you? 2. Use of birth control measures? No__ N/A__ Yes__ Type: _____________ 1. Observe behavior. Is the patient exhibiting any signs of alterations in mood
No__ Yes__ What? ___________________________________________ 3. History of vaginal discharge, bleeding, lesions: No__ Yes__ Describe: (anger, crying, withdrawal, etc.)? Describe: ________________________
3. Do you think this admission will result in any body changes for you? ___________________________________________________________ ___________________________________________________________
No__ Yes__ What? ___________________________________________ 4. Pap smear annually: Yes__ No__ Date of last pap smear: ____________
4. My usual view of myself is: Positive__ Neutral__ Somewhat negative__ 5. Date of last mammogram: ______________________________________ SUBJECTIVE
5. Do you believe you will have any problems dealing with your current health 6. History of sexually transmitted disease: No__ Yes__ Describe: _________ 1. Satisfied with the way your life has been developing? Yes__ No__ Comments:
situation? No__ Yes__ Describe: ___________________________ ___________________________________________________________ _________________________________________________
6. On a scale of 0 to 5 rank your perception of your level of control in this situation: 2. Will this admission interfere with your plans for the future? No__ Yes__ How?
___________________________________________________ If admission is secondary to rape: ______________________________________________________
___________________________________________________________ 7. Is patient describing numerous physical symptoms? No__ Yes__ Describe: 3. Religion: Protestant__ Catholic__ Jewish__ Muslim__ Buddhist__ None__ Other:
7. On a scale of 0 to 5 rank your usual assertiveness level: ______________ ___________________________________________________ _____________________________________________________
8. Is patient exhibiting numerous emotional symptoms? No__ Yes__ Describe: 4. Will this admission interfere with your spiritual or religious practices? No__ Yes__
ROLE-RELATIONSHIP PATTERN ___________________________________________________ How? ________________________________________________
9. What has been your primary coping mechanism in handling this rape episode? 5. Any religious restrictions to care (diet, blood transfusions)? No__ Yes__
OBJECTIVE ___________________________________________________ Describe: ___________________________________________________
1. Speech Pattern 10. Have you talked to persons from the rape crisis center? Yes__ No__ If no, want 6. Would you like to have your (pastor/priest/rabbi/hospital chaplain) contacted to
a. Is English the patient’s native language? Yes__ No__ Native language is: you to contact them for her? Yes__ No__ If yes, was this contact of assistance? visit you? No__ Yes__ Who? _________________________
__________________ Interpreter needed? No__ Yes__ No__ Yes__ 7. Have your religious beliefs helped you to deal with problems in the past?
b. During interview have you noted any speech problems? No__ Yes__ No__ Yes__ How?____________________________________________
Describe: ________________________________________________ Male
1. History of prostate problems? No__ Yes__ Describe: ________________ GENERAL
2. Family Interaction 2. History of penile discharge, bleeding, lesions: No__ Yes__ Describe: 1. Is there any information we need to have that I have not covered in this
a. During interview have you observed any dysfunctional family interactions? ___________________________________________________ interview? No__ Yes__ Comments? ______________________________
No__ Yes__ Describe: ___________________________ 3. Date of last prostate exam: _____________________________________ 2. Do you have any questions you need to ask me concerning your health, plan of
b. If patient is a child, is there any physical or emotional evidence of physical or 4. History of sexually transmitted diseases: No__ Yes__ Describe: ________ care or this agency? No__ Yes__ Questions: _________________
psychosocial abuse? No__ Yes__ Describe: ____________ ___________________________________________________________ ___________________________________________________________
_________________________________________________________ 3. What is the first problem you would like to have help with? ____________
Both ___________________________________________________________
SUBJECTIVE 1. Are you experiencing any problems in sexual functioning? No__ Yes__
Describe:___________________________________________________