INITIAL DATA BASE

Head of the family: ___________________________________ Family Number: _________________________________

Address: ___________________________________________

FAMILY STRUCTURE AND CHARACTERISTICS

Name Relation to head Sex Age Marital Educational Occupation Place Health
Status Attainment Type of work Remarks
HOME AND ENVIRONMENT Date Assessed: ________

1. Home
a. Ownership: ( ) Owned ( ) Rental ( ) real –Free
b. Construction Materials used: ( ) Light ( ) Mixed
c. Number of rooms used in sleeping: __________
d. Lighting Facilities: ( ) Electricity ( ) Kerosene ( ) Others Specify: ___________
e. General Sanitary Condition: ____________________________

2. Water Supply
a. Drinking Water
Source: ( ) Private ( ) Public
Distance from the house : _____________
Storage: ( ) none (direct from faucet or pipe)
( ) Jar or can with faucet
( ) Jar or can without faucet
( ) Others (specify) ______________

3. Kitchen
a. Cooking Facilities: ( ) electric stove ( ) gas stove ( ) Firewood
b. Sanitary Condition: _______________
c. Drainage Facility: ( ) none ( ) Open Drainage

4. Water Disposal
a. Refuse Garbage
(1) Container: ( ) covered ( ) open ( ) none
(2) Method of Disposal:
( ) Hog Feeding ( ) Composing
( ) Open Dumping ( ) Incineration
( ) Open Burning ( ) Others Specify: _______________
( ) Basial in Pit

b. Toilet
(1) Type
( ) None ( ) Antipolo System
( ) Pail System ( ) Water – sealed Latrine
( ) Open pit privy ( ) Flush Type
( ) Closed pit privy ( ) Others Specify: ________________
( ) Bored – hole latrine
( ) Overhung latrine
(2) Distance from the house: _______________________________________
(3) Sanitary Condition: ____________________________________________

5. Domestic Animals
Kind Number Where Kept
________________ __________________ ____________________
________________ __________________ ____________________

6. The Community in General

a. General Sanitary Condition: ________________________________________
______________________________________________________________
b: Housing Congestion: ( ) Yes ( ) No
c. Recreational Facilities: ___________________________________________
d. Availability of Health Care Facilities (Describe briefly) ____________________
______________________________________________________________
e. Distance of the house from the nearest health care facilities: ______________
 INITIAL DATE BASE FOR FAMILY NURSING PRACTICE

A. Family Structure and Characteristics

1) Members of the household and relationship to the head of the family

________________________________________________________________

2) Demographic Data
________________________________________________________________

3) Place of Residence of each member

________________________________________________________________

4) Type of Family Structure

________________________________________________________________

5) Dominant Family Members in matter of health care

________________________________________________________________

6) General Family Relationship

________________________________________________________________

B. Social-Economic and Cultural Factors

1) Income Expenses

a) Occupation place of work and income of each working member

____________________________________________________________
____________________________________________________________

b) Adequacy to meet basic necessities (food, clothing, and shelter)

____________________________________________________________
____________________________________________________________

c) Who makes decisions about the money and how is it spent?

____________________________________________________________
____________________________________________________________

2) Educational Attainment of each member

___________________________________________________________
___________________________________________________________
___________________________________________________________

3) Ethnic background and religious affiliation

___________________________________________________________
___________________________________________________________

4) Significant Others
___________________________________________________________

5) Relationship of the Family to Larger Community

___________________________________________________________
___________________________________________________________

C. Environmental Factors (refer to Home and Environment)

D. Health Assessment of each Member

1) Medical and Nursing History indicating illness, conducive to illness.

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

2) Nutritional Assessment (for vulnerable or at-risk members)

a. Anthropometric data
Mid-Upper arm circumference ______________
Height ______________
Weight ______________

b. Dietary History indicating quality and quantity of food intake

_____________________________________________________
_____________________________________________________

c. Eating/Feeding habit/Practices
_____________________________________________________
_____________________________________________________

3) Current Health Status Indicating Presence of Illness States

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

E. Valued Placed on Prevention of Disease

1) Immunization State of Children

______________________________________________________________
______________________________________________________________
______________________________________________________________

2) Use of other preventive services

______________________________________________________________
______________________________________________________________
______________________________________________________________
Name: ________________________________________

Clinical Experience: ______________________________

Clinical Area: ___________________________________

Date: _________________________________________

Time: _________________________________________

Clinical Instructor: _______________________________

FIRST LEVEL ASSESSMENT

A. HEALTH TREATS

B. HEALTH DEFICITS

C. FORESEEABLE CISIS/STRESS POINTS

Ranking of Family Health Problem According to Priorities

Problem: ____________________________________________________________

CRITERIA WEIGHT JUSTIFICATION

1, Nature of the Problem _ x 1

3

2. Modifiability of the problem _ x 2

2

3. Preventive Potentials _ x 1
3

4. Salience _ x 1
2

TOTAL = _______________

Problem: ____________________________________________________________

CRITERIA WEIGHT JUSTIFICATION

1, Nature of the Problem _ x 1

3

2. Modifiability of the problem _ x 2

2

3. Preventive Potentials _ x 1
3

4. Salience _ x 1
2

TOTAL = _______________
Problem: ____________________________________________________________

CRITERIA WEIGHT JUSTIFICATION

1, Nature of the Problem _ x 1

3

2. Modifiability of the problem _ x 2

2

3. Preventive Potentials _ x 1
3

4. Salience _ x 1
2

TOTAL = _______________

RANK ACCORDING TO PRIORITIES

1. ________________________________________________________________
2. ________________________________________________________________
3. ________________________________________________________________