Professional Documents
Culture Documents
College of Nursing
City of Tagbilaran
A.Household Members:
() Extended Family () Blended Family () Cohabiting Family (✔) Single Parent Family
Family Mobility
Length of time of current address:__11 YEARS_________________________________________
Address of Previous Residence: _NONE, _______________________________________________
Frequency of geographic move: __1________________________________________
Family Dynamics:
Emotional Bonding of Family Members__Closely-knit family
bonding_______________________________________
Distribution of Authority and Power _Agreed upon by both the husband and
wife___________________________________________
How members communicate_verbally & social media
Degree of social network with friends, neighbors and other relative _Often uses social media to connect
with other family members, friends and relatives____________________
Network with religious organizations (name of organization of which the family members are involve)
______none_________________________________________________________________
Network with Social Organizations (name of the organizations of which family members are involve)
____none__________
Educational: experience_College
graduate________________________________________________________
Leisure Time (Name some leisure time activities you are interested at)__eating, Watching Movies,
Cleaning house hold chores and , Chatting on messenger,____________________
___________________________________.
1. Home
a. Ownership- (✔) owned () rented () rent free
b. Construction Material
() light ✔ mixed () Strong
c. Number of bedrooms:_4__
d. Lighting facility
(✔) Electricity () Kerosene () Others (specify)_________________
b. Distance from the house: highway _motorcycle for 5 minutes count to water refilling
station_______________________________________
c. Storage:
() None (direct from the faucet)
✔ Large covered container with faucet
() Large uncovered container with faucet
() Others (specify)___________________
3. Kitchen
b. Food storage:
(✔) Covered () Uncovered (✔) Refrigerator
(✔) container with cover
() container without cover
() Open drainage
✔ blind drainage
None
4. Waste Disposal
a. Garbage container
b. Method of disposal
c. Excreta disposal:
✔Tank flush toilets (connected to septic tanks with sewerage system)
() Pour-Flush Latrine
() Antipolo toilet
() Pit latrine
() Shared
() none
Dog
Fish
7 Inside the house
Spider (Tarantula)
6. Pest and Vermin Control: Presence of breeding sites of insects, rodents, etc.
✔ No
() stray animals
F. Family Neighborhood
e. Sources of pollution
✔ cellphone
() landline Telephone
h. Transportation Facilities:
✔ own motorcycles
() rented vehicles
G. Family Health/Behavior
a. Activities of daily living (How the family spends a typical day)___Clean the surrounding, house
hold chores, Cooking, Preparing for meals. _________________
_________________________________________________________________.
b. Health History:
c. Self -Care Activities (name family’s related activities) __mother- mesicine maintenance for high
blood pressure losartan , father- medicine maintenance for hypertension
______________________________
() others (specify)_______________________________
Physical
complaints:________________HYPERTENSION___________________________________
Physical complaints:
_______________NONE__________________________________________
f. Common Illness encountered and management done
1-3
3-6
6-7
7-12
13-18
19-25
26-35
36-45
56-60
60-up
() Friends () Priest