GORDON S HEALTH ASSESSMENT TOOL

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A. BIOGRAPHIC DATA
1. Name: Jacob
2. Address: #18, Road II, Phase II, Doῆa Vicenta, Davao City 3. Age: 65 years old
4. Gender: Male
5. Date of birth: Oct. 15, 1948
6. Place of birth: Peῆaplata, Island Garden City of Samal
7. Ethnic Group: Bisaya
8. Primary language spoken: Visayan
9. Marital Status: Married
10. Educational: AB Political Science
11. Occupation: Retired Security Officer I
12. Religious orientation: Roman Catholic
13. Attending Physician and Clinic: Dr. Isaguirre / Mt. Apo Street, Davao City 14. Health Care financing and usual source of medical care: Family 15. Income: None

B. PAST HEALTH/MEDICAL HISTORY
1. Childhood
The patient cannot recall any illness during his childhood years. 2. College years
Chicken Pox
3. Immunizations
The patient is not sure if he was fully immunized during his younger years. However, he mentioned that when he was still working, they were given flu vaccines. 4. Allergies: The patient does not have any known allergies from food or drugs as well as dust, insects, etc. 5. Hospitalizations

a. 1980 – LBM; Dehydration
b. Dec. 10, 2010 – Amputation, 1st digit, Right foot
c. April 4, 2014 – Debridement, 1st digit, Right foot
6. Medications
a. Prescribed:
- Diamicron, Glucophage
b. Self-prescribed:
- OTC medications (Biogesic, Dulcolax)
7. Smoking and Alcoholic Drinking:
Smoking (Past) – 1 pack of cigarette per day.
Alcohol (Past) – Occasional drinker (20’s-50’s)
- 1 bottle (500ml) Tanduay per day (60’s)

C. FAMILY HISTORY OF ILLNESS
Jacob is the seventh among the eight children of Maria and Jose. Maria, his mother, was diagnosed to have Type II Diabetes Mellitus. She died on the 24th of June, 1983 at the age of 75 due to a heart attack, which is one of the complications of DM II. Jose, the father, had Liver Cirrhosis and died on the year 1980 at the age of 73.

Jacob’s siblings, John (eldest), Paul (second), and James (fourth) already passed away. John and Paul died on the year 1997 and 2001, respectively, at the age of 68 and 70 due to Liver Cirrhosis. James, on the other hand, died on the year 2010 at the age of 73 due to esophageal cancer. All of them are known smokers and alcoholic drinkers.

Jacob’s other siblings namely, Elijah (third), Luke (fifth), Abigail (sixth), and Isaiah (youngest) are still living. Luke, Abigail, and Isaiah are also diagnosed to have Type II Diabetes Mellitus. Elijah, on the other hand, is known to have hypertension.

D. HISTORY OF PRESENT ILLNESS
Jacob was diagnosed with Type II Diabetes Mellitus last November 25, 2000 after a Fasting Blood Sugar test. He cannot remember what the result was however; it was more than the normal. According to him, he was always thirsty and hungry. He also urinated a lot hence; he decided to seek medical advice. Though Jacob did not suspect he had diabetes, he was not shocked by the diagnosis since, his mother also had one.

According to Jacob, it took him almost 2 years before consulting his Doctor. He plays tennis three to four times a week hence; he thought it was just normal for him to feel thirsty and hungry almost all the time

After being diagnosed, Jacob was prescribed with oral hyperglycemics, Diamicron and Glucophage. He was also advised to watch his diet and to continue his sport, tennis. However, the progression of Jacob’s Diabetes was not prevented. He admitted that he is not following the meal plan advised to him and he is not taking his oral medications religiously.

After a few years, Jacob had a wound on the toe (first digit) of his right foot. The wound did not heal fast and after a few months time; Jacob observed a black discoloration around the wound. Jacob then decided to consult his Doctor. According to Jacob, the Doctor informed him that the reason why the wound did not heal is because of his uncontrolled diabetes. The doctor referred him to a surgeon and the surgeon decided to amputate the toe (first digit) of his right foot. This was done last December...