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Published by icywitch
Initial Data Base Format for Community Health Nursing
Initial Data Base Format for Community Health Nursing

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Published by: icywitch on Oct 04, 2010
Copyright:Attribution Non-commercial

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01/21/2011

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,1,7,$/'$7$%$6(
 Date Interviewed:Head of the Family: Family No.:
A
ddress:Type of Family Structure:
A
. Family Structure and Characteristics
FamilyMember No.
 Name Relation toHeadSex
Ag
e MaritalStatusHi
g
hest Educational
A
ttainmentOccupation Health RemarksType of Work Place
 
INITI
AL
D
A
T
A
B
A
SE FOR F
A
MI
LY
NURSING PR
A
CTICE
A
. Family Structure and Characteristics1.) Members of the household and relationship to the head of the family2.) Demo
g
raphic Data3.) Place of Residence of each member 4.) Type of Family Structure __________________________________________________________________5.) Dominant Family Members in matter of health care6.) General Family Relationship __________________________________________________________________B. Social-Economic and Cultural Factors1.) Income Expensesa. Occupation place of work and income of each workin
g
member  ______________________________________________________________ ______________________________________________________________b.
A
dequacy to meet basic necessities (food, clothin
g
, and shelter) ______________________________________________________________ ______________________________________________________________c. Who makes decision about the money and how it is spent? ______________________________________________________________ ______________________________________________________________2.) Educational
A
ttainment of each member  ________________________________________________________________ ________________________________________________________________ ________________________________________________________________3.) Ethnic back
g
round and reli
g
ious affiliation ________________________________________________________________ ________________________________________________________________4.) Si
g
nificant Others ________________________________________________________________
 
5.) Relationship of the Family to
L
ar 
g
er Community ________________________________________________________________ ________________________________________________________________
 
C. Environmental FactorsHOME
A
ND ENVIRONMENT Date
A
ssessed: _____________1. Homea. Ownership: ( ) Owned ( ) Rental ( ) real-Freeb. Construction Materials used: ( )
L
i
g
ht ( ) Mixedc. Number of rooms used in sleepin
g
: _______d.
L
i
g
htnin
g
Facilities: ( ) Electricity ( ) Kerosene ( ) Others Specify: _____e. General Sanitary Condition: _______________________________________2. Water Supplya. Drinkin
g
Water Source: ( ) Private ( ) PublicDistance from the house: ____________Stora
g
e: ( ) none (direct from faucet or pipe)( ) Jar or can with faucet( ) Jar or can without faucet( ) Others (specify) ________________3. Kitchena. Cookin
g
Facilities: ( ) electric stove ( )
g
as stove ( )firewoodb. Sanitary Condition: _____________________c. Draina
g
e Facility: ( ) none ( ) open draina
g
e4. Water Disposala. Refuse Garba
g
e1.) Container: ( ) covered ( ) open ( ) none2.) Method of Disposal:( ) Ho
g
feedin
g
( ) Composin
g
 ( ) Open Dumpin
g
( ) Incineration( ) Open Burnin
g
( ) Others Specify: __________( ) Basal in Pitb. Toilet1.) Type( ) None ( )
A
ntipolo System( ) Pail System ( ) Water-sealed
L
atrine( ) Open pit privy ( ) Flush Type( ) Closed pit privy ( ) Overhun
g
latrine( ) Bored-hole latrine ( )Others Specify: __________2.) Distance from the house: _______________________________________3.) Sanitary Condition: ____________________________________________5. Domestic
A
nimalsKind Number Where Kept _______________ _______________ _______________ _______________ _______________ _______________6. The Community in Generala. General Sanitary Condition: _______________________________________ ________________________________________________________________b. Housin
g
Con
g
estion: ( )
 Y
es ( ) Noc. Recreational Facilities: ___________________________________________d.
A
vailability of Health Care Facilities (Describe briefly) _________________ ________________________________________________________________e. Distance from the house to the nearest health care facilities: ___________

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