SAINT LOUIS UNIVERSITY

School of Nursing
FAMILY NURSING ASSESSMENT TOOL
Address of
(House #,

Family:

Pr. V, Pacis St., Middle Quezon Hill, Baguio City _____

Purok or Zone, Street #, Barangay, Municipality, Province)
SURVEYED / DATA GATHERED BY: _
REALUBIN, Dianne D.________
DATE SURVEYED / GATHERED:
October 30, 2015_______

FAMILY NAME:
GAYO
INFORMANT:
Jovelyn P. Gayo
NAME OF HEALTH CENTER:
Scout Bario
A. FAMILY STRUCTURE, CHARACTERISTICS AND DYNAMICS/RELATIONAL PATTERNS
FAMILY MEMBERS
RELATIONSHIP TO THE
POSITION/ORDER IN THE
BIRTHDATE
(include only those
HEAD (head, wife of
FAMILY / OTHER ROLES
(month & year)
living in the
head, son, daughter,
(Father & breadwinner, mother
household. Start
mother/father/in-law,
and store keeper, 1st child &
from the head then
niece/nephew, cousin,
cleaner, 2nd child and cook,
immediate
househelper, etc)
etc.)
members then nonmembers living with
family as last)
Elpidio Abat
Head
Father & Breadwinner
November 16,
1963
Jane Michelle Abat
Daugther
1st Child & Student
August 2,1992
John Edsel Abat
Son
2nd Child & Helper of the Family
July 6, 1994
Aaron Abat
Son
3rd Child & Student
July 16, 1999
Gerald Abat
Son
4th Child & Domestic Helper
March 1, 2003
Jeric Rivera
Son in Law
Mason & Husband of the 1st
February 09, 1992
Child
Jericho Rivera
Grandson
Son of the 1st Child
October 6, 1994

AGE
(should be
exact in
years and in
months)

GENDER

MARITAL STATUS

PLACE OF RESIDENCE / WORK /

STUDY (including nonemancipated working or studying
family members whether living
with family or elsewhere)

DOMINANT DECISION
IN MATTERS O
(Please check appr
column below
HEALTH &
M
CARE
EX
TENDING

52

Married

None

23
21
16
12
23

F
M
M
M
M

Single
Single
Single
Single
Single

U.C.
Green Valley
City High
Mabini
Bokawkan

Single

None

TYPE OF FAMILY:
FAMILY
DYNAMICS/COMMUNICATION
PATTERNS/INTERACTIONAL
PROCESSES:
(describe
the
characteristic
communication/interaction patterns between/
among subsystems evidences of love, openness/warmth, caring/helping,
listening, ability to handle conflict, change, anticipated and unexpected events;
According to structure & composition: Extended Family
evidences of presence or absence of any obvious or readily observable conflict/s between members, etc.)
According to family head and decision making: Patriarchal
Spouse subsystem: ___________________________________________________________________________________________________
According to roles/bread-earning: Patriarchal
Parent-child
subsystem:
______________________________________________________________________________________________________
Sibling-sibling
subsystem: _________________________________________________________________________________________________

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SAINT LOUIS UNIVERSITY

School of Nursing

B. SOCIO-ECONOMIC AND CULTURAL CHARACTERISTICS

FAMILY MEMBERS
HIGHEST EDUCATIONAL
RELIGIOUS AFFILIATION
ATTAINMENT (last level
RELIGIOUS SECT WHERE
WHAT RELIGIOUS SECT IS
completed at the time of
BAPTIZED
THE MEMBER ACTIVE
survey & none)
Elpidio Abat
Undergraduate College
Born Again
Born Again
Jane Michelle Abat
John Edsel Abat
Aaron Abat
Gerald Abat
Jeric Rivera
Jericho Rivera

2nd Year College

High School
High School
Elementary
High School
None

Born
Born
Born
Born
Born
Born

Again
Again
Again
Again
Again
Again

Born
Born
Born
Born
Born
Born

Again
Again
Again
Again
Again
Again

ETHNIC BACKGROUND

OCCUPATION

Ilocano

Retired Maintenance
Worker
Student
Laborer
Student
Student
Mason
None

Ilocano
Ilocano
Ilocano
Ilocano
Ilocano
Ilocano

INCOME (gathering this

data requires non-leading
& non-embarassing
questions)
None

OTHER SOUR
INCOME

None
Php 3,000.00
None
None
Php 3,000.00

Sari- Sari S

None
None
None
None
None

BUDGET AND ACTUAL EXPENSES (Please specify in the table if the budget and expenses is daily, weekly or monthly-based. Questions to elicit this set of data should be very discreet, non-direct and nonembarassing):
BASIC NECESSITIES
BUDGET
ACTUAL EXPENSES
CONCLUSION: ADEQUACY TO MEET BASIC NECESSITIES USING THE TOTAL INCOME, BUDGET AND A
EXPENSES AS BASIS
Food and water
Php 2,000.00
Php 2,000.00
Adequate (income=budget and actual expenses); inadequate (actual expenses exceeds budget and
more than adequate (income exceeds actual expenses)
Shelter (home maintenance/repairs, rent)
Php 500.00
Php 400.00
Clothing
Php 500.00
Php 300.00
Education
Php 5,000.00
Php 5,000.00
Health
Php 1000.00
Php 500.00
Electricity, electronics, communication and other
Php 500.00
Php 300.00
services
Others (car repair/maintenance, gasoline, etc.)
Php 0.00
Php 0.00
TOTAL
Php 9,500.00
Php 8,500.00
SIGNIFICANT OTHERS OF THE FAMILY
NAME/S OF SIGNIFICANT MEMBERS

PLACE OF RESIDENCE

ROLES PLAYED IN THE FAMILY

SUPPORT THAT THEY PROVIDE

FAMILY
TRADITIONS,
EVENTS
OR
PRACTICES
THAT
AFFECT
MEMBERS
HEALTH
OR
FAMILY
FUNCTIONING
(please
describe):
____________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________

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SAINT LOUIS UNIVERSITY

School of Nursing

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