INITIAL DATA BASE

I. CHARACTERS:
A. What is the type of family structures?
______ Nuclear _______ Patriarchal
__ / ​Extended _______ Matriarchal
B. Who makes decision regarding health care? ​WIFE
C. What is the present family relationship?
__________ with conflicts between members
/ ​without conflicts between family members
D. Activities of daily living:
1. Sleeping pattern:
Retiring/getting up hours ​SLEEPING TIME 10:00 P.M. WAKING TIME 8:00 A.M.
Nap during the day ​2-3HRS AROUND 1:00 P.M.
Do members sleep together ​YES
2. Eating pattern
How many meals each day? ​4 MEALS EACH DAY
Who appears overweight? ​NONE OF THEM
Who appears underweight? ​NONE
3. Leisure time activities
How does each member spend leisure hours? ​PLAYING MOBILE GAMES, GARDENING
Is it appropriate for the sex and age group? ​YES
What is the effect to the family? ​NONE
Any joint activity for leisure? ​PLAYING MOBILE GAMES

II. FAMILY INFORMATION

Head of the family:
Address: ​QUEZON CITY
Members of the household: ​ MEMBERS

NAME RELATIONSHIP AGE EDUCATIONAL ATTAINMENT

ALL HEAD OF THE FAMILY 53 COLLEGE UNDERGRADUATE
(HUSBAND)
RYL WIFE 50 COLLEGE UNDERGRADUATE
DYL SON 20 COLLEGE LEVEL
RYL SON 19 COLLEGE
IYL SON 18 SHS
PYL DAUGHTER 15 SHS

III. SOCIO-ECONOMIC AND CULTURAL FACTORS

A. Income

NAME OCCUPATION PLACE INCOME

ALL MANAGER N/A 50,000

1. Does the working family member meet the basic necessities?

/ ​ Yes _____ No
 2. Who makes decisions regarding money matters? ​WIFE
3. Religious affiliation: ​CATHOLIC
4. What roles does the family play in the community? ​NONE

IV. ENVIRONMENTAL FACTORS

A. Housing
1. Ownership
_________ Owned ________ Rented / ​ Rent-Free
2. Construction materials used
_________ Light ​ / ​ Mixed ___________ Strong
3. Living space
/ ​ Adequate ________ Inadequate
4. Sleeping arrangement: ​SLEPT WITH DIFFERENT ROOMS
5. Adequacy in furniture
/ ​ Adequate ________ Inadequate
6. Water source
/ ​ Private ________ Public
7. Food storage
/ ​ Refrigerator ________ Jars/container
8. Cooking facility
/ ​ Electric stove ________ Firewood
/ ​ Gas Stove ________ Kerosene
9. Drainage facility
/ ​ Open drainage ________ Blind drainage ________ None
10. Toilet facilities/type
_________ Flushed ___________ Over hung latrine
_________ Bored-hole latrine / ​ Water-sealed latrine
/ ​ Pail system ___________ None
11. Sanitary condition
/ ​ Fair ___________ Good ________ Poor
12. Neighborhood
_________ Congested ___________ Slum / ​ Other
13. Availability of Health Care Facility
Describe briefly:​ APRROXIMATELY 2 KM. AWAY FROM THE HEALTH CENTER
14. Garbage disposal
__________ Dumped at street corner / ​ Picked up by garbage collector
__________ Buried ____________ Burned then buried

V. HEALTH MEDICAL HISTORY

A. Presence of illness
_______ Diagnosed _________ Undiagnosed ________ None

NAME PAST ILLNESS ILLNESS STATE HEALTH ACTION TAKEN

ALL STROKE NOT ACTIVE TAKING MAINTENANCE

Hypertention
 Disturbed sleeping
pattern

VI. VALUE PLACED ON PREVENTION OF DISEASE

NAME AGE COMPLETE INCOMPLETE

M.G.P. 38

Preventive practices employed by the family: _________________________

Sources of Health Care:
_________ Health Center ____________ Government Hospital
/ ​ Private Hospital ____________ Others