SAINT LOUIS UNIVERSITY

School of Nursing
FAMILY NURSING ASSESSMENT TOOL

Address of Family: #02 Brgy. Malagyao, Kapangan

(House #, Purok or Zone, Street #, Barangay, Municipality, Province)

FAMILY NAME: Balong SURVEYED / DATA GATHERED BY: ACOSTA, Rose Angela R.
INFORMANT: Angelita Balong DATE SURVEYED / GATHERED: November 22, 2017
NAME OF HEALTH CENTER: Gambang health center

A. FAMILY STRUCTURE, CHARACTERISTICS AND DYNAMICS/RELATIONAL PATTERNS

FAMILY MEMBERS RELATIONSHIP TO THE HEAD POSITION/ORDER IN THE FAMILY BIRTHDATE AGE GENDER MARITAL PLACE OF RESIDENCE / WORK / STUDY DOMINANT DECISION MAKERS IN
(Include only those living in the (head, wife of head, son, daughter, / OTHER ROLES (month & year) (should be (male, female, STATUS (include addresses of non- MATTERS OF:
household, but non-emancipated mother/father/in-law, (Father & breadwinner, mother exact in middle sex) emancipated/emancipated single (Please check appropriate column
children studying elsewhere or niece/nephew, cousin, and store keeper, 1st child & years and members studying or living elsewhere below)
emancipated single members working househelper, etc) cleaner, 2nd child and cook, etc.) in but goes home on regular basis) HEALTH & CARE MONEY &
who go home regularly to this family months) TENDING EXPENSES
will still be included here. Start from the
head then immediate members then
non-members living with family as last)
Wilmer Balong Head Father April 20, 1960 57 y/o & 4 Male M Malagyao
months
Angelita Balong Wife of Head Mother January 20, 1963 54 y/o & 5 Female M Malagyao
months

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: Empty Nest Family evidences of presence or absence of any obvious or readily observable conflict/s between members, etc.)
According to locus of power (family head and decision making): Patriarchall Spouse subsystem: Very caring, loving and responsible at all times.
According to roles/bread-earning : Patriarchal Parent-child subsystem: The Daughters and son already moved out because they have their own family.
Sibling-sibling subsystem: Siblings are very loving to each other and willing to help with each other.

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 SAINT LOUIS UNIVERSITY
School of Nursing

B. SOCIO-ECONOMIC AND CULTURAL CHARACTERISTICS

FAMILY MEMBERS HIGHEST EDUCATIONAL RELIGIOUS AFFILIATION ETHNIC BACKGROUND OCCUPATION INCOME (gathering this data OTHER SOURCES OF INCOME
ATTAINMENT (last level RELIGIOUS SECT WHERE WHAT RELIGIOUS SECT IS THE requires non-leading & non-
completed at the time of survey) BAPTIZED MEMBER ACTIVE embarassing questions)
Wilmer Balong Elementary Graduate Baptist Church Baptist Church Kankanaey Farmer N/A Son & Daughter
Angelita Balong Elementary Graduate Baptist Church Baptist Church Kankanaey Farmer N/A Son & Daughter

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 non-embarassing):
BASIC NECESSITIES BUDGET ACTUAL EXPENSES CONCLUSION: ADEQUACY TO MEET BASIC NECESSITIES USING THE TOTAL INCOME, BUDGET AND ACTUAL EXPENSES AS BASIS
Food and water N/A N/A Adequate (income=budget and actual expenses); inadequate (actual expenses exceeds budget and income); more than
Shelter (home maintenance/repairs, rent) N/A N/A adequate (income exceeds actual expenses). (Other standard bases of comparison here will be the official poverty line and an
Clothing N/A N/A honest evaluation of the family about the adequacy of their income).
Education N/A N/A
Health N/A N/A
Electricity, electronics, communication and other services N/A N/A
Others (car repair/maintenance, gasoline, etc.) N/A N/A
TOTAL N/A N/A

SIGNIFICANT OTHERS OF THE FAMILY

NAME/S OF SIGNIFICANT MEMBERS PLACE OF RESIDENCE ROLES PLAYED IN THE FAMILY SUPPORT THAT THEY PROVIDE
Hilton Balong Malagyao Eldest Food, Medicine
Sara BAlong Malagyao Youngest Food, Medicine

FAMILY TRADITIONS, EVENTS OR PRACTICES THAT AFFECT MEMBERS HEALTH OR FAMILY FUNCTIONING (please describe): NONE

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