famil

COMMUNITY HEALTH NURSING

Family survey form

Submitted by: Group 2

Aspa, Arceli Liane
Bello, Kitz Irish
Camello, Annalyn
Diaz, Susan diaren
Dominise, Ivin Janice Mishaila
Floralde, Carmela An
Hernandez, Christine Joy
 Family Service and Progress record
HEAD OF THE FAMILY:_________________________________________________ FAMILY NUMBER:___________________________________
ADDRESS:__________________________________________________________________________________________________________________

I. Assessment of the Family, Home and Environmental Conditions:

A1. Members of the Household

FAMILY MEMBER RELATIO SEX BIRTHDATE MARITAL HIGHEST OCCUPATION REMARKS /

N TO STATUS EDUC. DATE
HEAD COMPLETED ENTERED
No. Name Month Year Type place
of
work

A2. Family Members not residing in the household but affect family resource generation and use

FAMILY MEMBER RELATION SEX BIRTHDATE MARITAL HIGHEST OCCUPATION REMARKS /

TO HEAD STATUS EDUC. DATE
COMPLETED ENTERED
No. Name Month Year Type place
of
work
A. Home and Environment
Date Assessed: ______________________________
1. Home
a. Ownership: ( ) owned ( ) rented ( ) rent-free
b. Construction materials used: ( ) Light ( ) Mixed ( ) Strong
c. Number or rooms used for sleeping: ___________________
d. Ventilation: ( ) poor ( ) good
e. Lighting Facilities: ( ) Electricity ( ) Kerosene ( ) Others: Specify
f. Location (e.g., urban or rural, subdivision, slum area) ___________________________________________________
g. Type (e.g., residential, semi commercial) _____________________________________________________________
h. General sanitary condition: ________________________________________________________________________
2. Drinking Water Supply
Source: ( ) artesian well ( ) NAWASA
( ) deep well
Portability: _________________________________________________________
Distance from house: ________________________________________
Storage: ( ) none (direct from faucet or pipe)
( ) refrigerated
( ) large uncovered container without faucet
( ) others, specify __________________
Containers used:
( ) plastic ( ) clay jars
( ) bottles others: __________________________________________
3. Kitchen
Cooking facility: ( ) electric stove ( ) gas stove ( ) firewood/charcoal
Sanitary condition: _____________________________________________________________________________
Drainage facility: ( ) open drainage ( ) blind drainage ( ) none
4. Waste Disposal
a. Refuse and garbage
Container: ( ) covered ( ) open ( ) none
Method of disposal:
( ) hog feeding ( ) open burning
( ) open dumping ( ) garbage collection
( ) burial in pit ( ) others, specify: ____________________________
( ) composting
b. Toilet
Type:
Sanitary
( ) none ( ) pail system
( ) overhung latrine ( ) Antipolo type
( ) open pit privy ( ) water-sealed latrine
( ) closed pit privy ( ) flush type
( ) bored-hole latrine
( ) others, specify: _________________________________________________________________

Unsanitary
( ) “ballot system” others ________________
 Distance from house: _______________________________________________________________________
Sanitary condition: _________________________________________________________________________
5. Food storage:
( ) covered ( ) uncovered
( ) refrigerated
6. Background gardening:
( ) vegetables ( ) herbal
( ) fruit-bearing others _______________
7. Domestic animals:
Kind Number Where kept

8. The Community in General

a. General sanitary condition: _____________________________________________________________________
b. Housing congestion: ( ) Yes ( ) No
c. Presence of Breeding Sites of Vectors of Diseases:
( ) Yes; Specify _________________________
( ) None
d. Recreational facilities: __________________________________________________________________________
e. Availability of health care services (describe briefly): _________________________________________________
____________________________________________________________________________________________
f. Distance of house from nearest health care facility: ___________________________________________________
____________________________________________________________________________________________

II. Socio-Economic Data

 A. Source of Income
Occupation:
Husband
Wife
( ) Employed ( ) Unemployed
( ) Self-employed
Monthly Income:
( ) Below ₱ 2,000 ( ) ₱2,000-₱5,000
( ) ₱5,001-₱8,000 ( )more than ₱8,000
B. Family Expenditures
1. Food
( ) Below ₱50 ( ) ₱50-75
( ) More than ₱70
2. Clothing: number of times of times of buying
( ) Once a year ( ) twice
( ) Thrice
3. Housing
( ) Water ( ) electricity
( ) Telephone
( ) Schooling
4. Schooling
( ) Public ( ) private
5. Others _________________________________________

III. Knowledge, Attitude and Practice

A. Do you utilize the health center? ( ) Yes ( ) No
If no, why? ___________________________________________________________________
B. Reason:
( ) illness ( ) prenatal
( ) family planning ( ) postnatal
( ) dental ( ) nutrition
C. First person consulted in times of illness:
( ) M.D. ( ) nurse
( ) Midwife ( ) “hilot”
( ) “herbularyo” ( ) BHW
Others ______________________________
D. Usual illness in the family
____________________________________________________________________________
____________________________________________________________________________
What do you do for this condition?
( ) Self-medication ( ) consultation
( ) hospital ( ) private clinics
( ) nursing others _______________________
E. Other diseases
( ) TB ( ) Leprosy
( ) Skin disease ( ) Hepatitis
Others ____________________
F. Do you submit your children (0-12 months) for immunization?
Name of child Birthday Immunization
BCG DPT OPV AM
 G. Do you practice family planning? ( ) Yes ( ) No
Method:
If no, why? __________________________________________________________________
H. Method of infant feeding
( ) breast ( ) bottle
( ) mixed
I. Subjects you want to learn in health education:
( ) drug douse ( ) nutrition
( ) family planning ( ) herbal plants
( ) first aid measure others __________________
IV. Cultural influences: Values, attitude and beliefs about:
A. Spirituality
_______________________________________________________________________________________________________________
B. Rituals (holidays and celebration)
_______________________________________________________________________________________________________________
C. Dietary habits:
_______________________________________________________________________________________________________________

D. Health:
_______________________________________________________________________________________________________________
E. Folk Diseases:
_______________________________________________________________________________________________________________
F. Traditional healers:
 _______________________________________________________________________________________________________________
V. Family Dynamics
A. Emotional bonding of Family members:
_______________________________________________________________________________________________________________
B. Distribution of authority and power:
_______________________________________________________________________________________________________________
C. Degree of individual autonomy:
_______________________________________________________________________________________________________________

D. How members communicate:

_______________________________________________________________________________________________________________
E. How decisions are made:
_______________________________________________________________________________________________________________
F. How problems are solved:
_______________________________________________________________________________________________________________
G. How conflict is handled:
_______________________________________________________________________________________________________________

VI. Socioeconomic and cultural characteristics

A. Language(s) or dialect(s) spoken:
_______________________________________________________________________________________________________________
B. Literacy (ability to read/write in language(s)
_______________________________________________________________________________________________________________
C. Degree of social network w/ friends, neighbors and other relatives:
 _______________________________________________________________________________________________________________
D. Network with religious organizations:
_______________________________________________________________________________________________________________
E. Network with social organizations:
_______________________________________________________________________________________________________________
F. Adequacy of financial resources:
_______________________________________________________________________________________________________________
G. Leisure time interest:
_______________________________________________________________________________________________________________

VII. Community Resources

A. Health and other facilities
( ) health center ( ) barangay hall
( ) school ( ) church
( ) park ( ) market

B. Indigenous health workers

( ) trained “hilot” ( ) BHW
( ) herbularyo ( ) untrained “hilot”
Others ____________________
C. Sources of health funds:
( ) government ( ) private
NGOs/ Pos Others _____________________________________________________
VIII. Nutrition
A. Food preference
 ( ) Fish ( ) fruits / vegetables
( ) Meat ( ) mixed
B. Common fare
( ) rice and egg ( ) rice and sardines others
( ) Rice and noodles
C. Presence of nutritional disorder
1. Goiter
( ) enlargement of neck ( ) dysphagia

( ) hoarseness others __________________________

2. Anemia
( ) pallor ( ) easy fatigability
( ) body weakness
3. Vitamin A deficiency
( ) night blindness
Others _____________________________

A. Health Condition and Problem Sheet

HEALTH CONDITIONS NURSING PROBLEMS SUPPORTING / CUES DATE
AND PROBLEMS
IDENTIFIED RESOLVED
B. Nursing Care Plan
HEALTH CONDITION/S OBJECTIVES OF PLANS OF PRINTED NAME
OR PROBLEM/S AND NURSING CARE INTERVENTION AND SIGNATURE
FAMILY
NURSING PROBLEMS
OUTCOME CRITERIA/ METHODS/
INDICATORS, TOOLS
STANDARDS

C. Service and Progress Notes

DATE HEALTH CONDITIONS / NURSING OBSERVATIONS, ACTION/S TAKEN, PRINTED NAME
NURSING RESPONSES and EVALUATION OF AND SIGNATURE
PROBLEMS PROGRESS/OUTCOMES
Interviewed by: _____________________________
Date: _________________Time: _______________