I.

INITIAL DATABASE FOR FAMILY NURSING PRACTICE

A. Family, Structure, Characteristics, and Dynamics

Name of Position in Age Sex Civil Nationalit
Household the Family Status y
Members

B. Socio-Economic and Cultural Characteristics

Name of Occupation Place of Income of Educational

Household Work each working Attainment
Members member

C. Home and Environment

D. Health Status of each Family Member

Medical and Nursing History

1. Present illnesses

2. Past illnesses Father:

Mother:
Daughter:
Son:

3. Family History

3.1 Mother’s Side

3.2 Father’s side

4. Health practices of the family

when someone is ill
 5. Health beliefs

6. Health complaints

7. Health teachings/advice they

got from their doctor

8. Immunizations given to the family members (complete/incomplete)

8.1 Father

8.2 Mother

8.3 Daughter

Nutritional Assessment: Anthropometric Data of the Family Members

Family Weight Height Body Waist Mid-upp Waist

Member (kg) (m) Mass circumfe er arm hip ratio
Index rence Circumfe (WHR)
(BMI) (WC) rence

Dietary history

1. Quantity of meals eaten per

day

2. Type of diet followed by

family/family members

3. Eating habits/practices

4. Type of food prepared by the

family

5. Health
supplements/medications
 taken by family/family
members

5.1 Father

5.2 Mother

5.3 Daughter

5.4 Son

1. Type of lifestyle practiced by the family (extremely inactive,

sedentary, moderately active, vigorously active, extremely active)

1.1 Father

1.2 Mother

1.3 Daughter

1.4 Son

2. Past/present vices of a family member

2.1 Father

2.2 Mother

2.3

4. Type of physical activity done by each family member

4.1 Father

4.2 Mother

4.3 Daughter

4.4 Son

E. Values, Habits, Practices on Health Promotion, Maintenance and Disease

Prevention