ASSESSMENT DATA BASE IN FAMILY NURSING PRACTICE

Direksyon: Sagutan ng naayun ang mga sumusunod na katanungan, base sa mga datus na makukuha sa
pamilyang sinusuri,

A. Family structure, Characteristics and Dynamics/Relational Patterns

Pangalan ( Mga miyembro Edad Kaarawan Kasarian Civil Posisyon sa Relasyon sa Ulo
ng pamilya na naninirahan Status Pamilya ng tahanan/
sa bahay) pamilya

1. Mother M.J.P 47 November Babae Others Mother Wife

12, 1971 (live-in
partner)

2. Father J.O 46 September Lalaki Others Father Head of the

28, 1974 (live-in Family
partner)

3. Daughter J.O 24 July 16, Babae Single Son Son

1995

4. Son G.O 18 April 8, Lalaki Single Son Son

2001

5. Daughter J.O 16 October 5, Babae Single Daughter Daughter

2002

6. Grandmother N.P 70 September Babae Married Grandmother Mother-in-law

27, 1949

7. Grandfather A.P 72 March 25, Lalaki Married Grandfather Father-in-law

1947

8. Sister-in-law J.C 35 July 23, Babae Married Sister-in-law Sister-in-law

1948

9. Brother A.C 37 April 22, Lalaki Married Brother Brother-in-law

1982

10. Nephew A.D.C 7 November Lalaki Single Nephew Nephew-in-law

23, 2012

11. Niece N.L.C 10 months November Babae Single Niece Niece-in-law

25, 2018

12. Brother R.P 51 October 20, Lalaki Married Brother Brother-in-law

1968

13. Sister-in-law I.P 47 January 15, Babae Married Sister-in-law Sister-in-law

1972

14. Nephew C.L.P 26 March 25, Lalaki Single Nephew Nephew-in-law

1993

15. Nephew C.P 25 September Lalaki Single Nephew Nephew-in-law

12, 1994
16. Nephew P.P 23 December Lalaki Single Nephew Nephew-in-law
9, 1996

17. Nephew R.P 20 January 17, Lalaki Single Nephew Nephew-in-law

1999

18. Niece P.P 10 November Babae Single Niece Niece-in-law

17, 2009

19. Nephew C.P 16 November Lalaki Single Nephew Nephew-in-law

2, 2003

Pangalan (Mga miyembro ng

pamilya na hindi nakatira sa
bahay ngunit tumutulong sa
paghahanap ng ikabubuhay
ng pamilya at kung san ito
gagamitin o ilalaan.

1. Sister M.A.P 37 June 20, Babae Single Sister Sister-in-law

1982

2. Brother A.P 46 January 21, Lalaki Married Brother Brother-in-law

1974

3. Sister-in-law A.S.P 55 December Babae Married Sister-in-law Sister-in-law

13

1. Uri ng Istraktura ng Pamilya

____ Patriarchal (Ama ang ulo ng Tahanan) ___ Matriarchal ( Ina ang ulo ng tahanan)

Nuclear (magulang at mga anak lamang) ___

Extended o Blended (kasama ang lola, lolo, kapatid at mga pinsan) ___

2. Kanino po nanggagaling ang mga dedesisyon sa pamilya pagdating sa kalusugan o pagbibigay alaga sa
pamilya? ___Ama ____Ina _____Ama at Ina Iba pang miyembro ng pamilya,tukuyin :_______

3. Magbigay po kayo na maikling pagsasalawaran ng relasyon ng mga miyembro na pamilya tulad ng

pagkakaroon nang maayus na pakikipag-usap at interaksyon lalo na sa pagtalakay ng mga isyu na
nkakaapekto sa pamilya ( Hal: mga isyu na may kinalaman sa pagresolba ng mga suliranin, kapag may mga di
inaasahang pangyayari na naapektuhan ang buong pamilya, pagkakasakit ng ilang meyembro ng pamilya at
iba pang mahahalagang isyu).

- “Nag-uusap kami ng mahinahon kapag may problema katulad ng pang pinansyal na problema. Mayroon
kaming maayos na relasyon sa isa’t isa.”

- We are fixing the issues like financial problems calmly as much as we can. We have good relationship with
each other.

B. SOCIO-ECONOMIC AND CULTURAL CHARACTERISTICS

1. Sahod at Mga Pinagkakagastusan

 Pangalan ng Kinabibilangan Tribu/ Relihiyon Pinakamataas Trabaho Lugar na Sahod/buwan Halaga ng
Miyembro ng Pangkat na Antas ng ( Kung Pinag- gastusin/buwa
Pamilya Edukasyon na kasalukuyang tratrabahu n
Naabot nag-aaral pa , han
ilagay ang
kasalukuyang
antas

1. Mother M.J.P N/A Roman High School Housewife N/A N/A 900 php
Catholic

2. Father J.O N/A Roman Elementary Tricycle Batangas 3,000 php 9,000 php
Catholic Driver St.

3. Daughter J.O N/A Roman College Purchasing United 13,000 php 3,000 php
Catholic graduate Staff Nations
Contribution
(Business
to the family:
Managemen
3,000 php –
t) water,
electricity,
and rent

4. Son G.O N/A Roman Undergradua N/A N/A N/A 3,900 php
Catholic te (1st year
college)

5. Daughter J.O N/A Roman Senior High N/A N/A N/A 1,200 php
Catholic School

6. Grandmother N/A Roman High School Housewife N/A N/A

N.P Catholic
8,000 php
7. Grandfather N/A Roman High School Unemployed N/A 3,600 php
A.P Catholic (pensioned)

8. Sister-in-law N/A Roman College Encoder Valenzuel 13,000 php

J.C Catholic a
Contribution
to the family:
2,000 php –
water and
electricity

9. Brother A.C N/A Roman Undergradua Sales Caloocan 13,000 php

Catholic te 6,520 php
Contribution
to the family:
1,500 php -
rent

10. Nephew N/A Roman Elementary N/A N/A N/A

A.D.C Catholic (Grade 1)

11. Niece N.L.C N/A Roman N/A N/A N/A N/A

Catholic

12. Brother R.P N/A Roman Undergradua Messenger N/A N/A N/A
Catholic te (3rd year
 college)

13. Sister-in-law N/A Roman High school Housewife N/A 3,000 php 4,000 php
I.P Catholic
Contribution
to the family:
500 php -
bigas

14. Nephew N/A Roman College (BS Insurance Makati 13,000 php 5,600 php
C.L.P Catholic Entrepreneu agent
Contribution
rship)
to the family:
1,500 php –
water and
electricity

15. Nephew C.P N/A Roman College Teller Intramuro 13,000 php 4,400 php
Catholic (Business s
Contribution
Managemen
to the family:
t)
1,500 php -
rent

16. Nephew P.P N/A Roman College Office staff Binondo 13,000 php 2,500 php
Catholic (Information
Contribution
Technology)
to the family:
1,400 php –
allowance for
the siblings

17. Nephew R.P N/A Roman College Office staff Makati 12,000 php 2,000 php
Catholic (Social Work) (PNB –
Contribution
Housing
to the family:
Loan)
1,400 php –
allowance for
the siblings

18. Niece P.P N/A Roman Senior High N/A N/A N/A 1,600 php
Catholic School

19. Nephew C.P N/A Roman High School N/A N/A N/A 1,200 php
Catholic (Grade 10)

2. Sapat po ba ang kinikita ng pamilya para sa iyong pangunahing gastusin? ______Oo _______Hindi

3. Sino po ang nagdedesisyon sa inyong pamilya pag dating sa pera at kung paano at saan ito gagamitin?

_______Ama _______Ina _________ buong pamilya _________Iba pang tao,tukuyin

4. May mga tradisyon o sinasagawa po ba kayong mga kasanayan (Practices) sa pamilya na may kinalaman sa inyong
kalusugan at pamumuhay? ________Meron ________Wala

Kung meron, isalarawan ang mga mga ito:

- “Albularyo, kapag hindi nakuha sa Doctor; Nuno”

- Faith healers, if the treatment given by the doctor is not effective. Superstitions (e.g. Nuno)

Justification: Naniniwala ang kanilang pamilya sa albularyo dahil gumaling umano ang kanilang Tatay noong
nagkaroon siya ng pamamaga sa kaniyang mga paa’t kamay. _ taon ang inabot ng kanilang pamilya sa pagpapagamot
ng kanilang ama sa doctor. Ngunit, gumaling umano ito sa loob ng tatlong araw pag katapos mag pa-albularyo.

5. Bukod sa mga miyembro nang pamilya, meron pa po bang ibang mga tao na may tungkulin na mahalagang
ginagampanan sa pamilya? Sinu po ito at anu ang mahalagang papel ang kanyang ginagampanan sa pamilya nyo?

- Congressman (Student scholarship) - 4Ps (financial support)

- PCSO (Medical assistance for dialysis)

6. Kamusta po ang relasyon ng inyong pamilya sa inyong komunidad?

- “Maayos naman silang makasama”

- They had a great cooperation

7. Anu-ano po ang mga programa sa komunidad kung saan ang inyong pamilya ay nakikilahok o nakikibahagi:

_________________ medical mission _________________family day

_________________ paglilinis sa komunidad (TUPAD) Iba pa, tukuyin: Zumba

__________________ programang pang kabuhayan (livelihood programs)

C. HOME AND ENVIRONMENT

1.) Kabahayan
A. Espayo ng kabahayan
_____masikip ____maluwag _____sapat lamang

Justification:
 Area of each room: 46 sqm
 No. of family members: 1st room – 5; 2nd room – 7; 3rd room - 7
 Adequate space for one person: 9.3 sqm – 37.1 sqm
Reference: According to the engineering toolbox, the average person needs about 100-400 sqm
space to feel comfortable in a home (https://youngandthrifty.ca/how-much-space-do-you-really-
need)
 Photo evidence refer to Appendix photos 1-4
B. Kasunduan sa Pagtulog ( sakaling di lahat ng miyembro ng pamilya ay kasya sa bahay)
________ shifting __________nakikitulog sa ibang bahay
________ pilit nalang pinagkakasya

Justification:
 Some family members sleep on the floor, some use double deck
 Photo evidence refer to Appendix photos 2-3

C. May lugar sa bahay na maaring pamahayan ng mga insekto /hayop na nagdadala ng sakit tulad ng
ipis, lamok, daga at iba pa. (Ibase ang sagot sa interview at sariling obserbasyon)
_______meron _____wala
 Justification:
 Open canal in front of the house
 Water drainage is clogged that can easily cause flood
 Photo evidence refer to Appendix photos 5-9

D. May mga bagay ba sa loob nang bahay na maaring maging kadahilanan ng aksidente o sunog?
______Meron ______Wala
Kung meron tukuyin ang mga ito: tulay papuntang bahay (stepping flatform), house made of light
materials

Justification:
 The house was built with light and easily flammable materials (e.g. wood)
 Improper use of extension wires
 Photo evidence refer to Appendix photos 6, 10, 11

E. Paraan ng pag -imbak ng pagkain at mga pacilidad sa pagluluto

San po ninyo iniimbak ang inyong mga pagkain?
________refrigerator
_________kabinet
_________tintakpan lamang sa lamesa
Iba pang paraan, tukuyin:__________________________________________________

Alin sa mga gamit sa pagluluto ang mayroon kayo?

__________kalan de kuryente Iba pang gamit, tukuyin: _________________
__________kalan na de gasul ____________________________________
__________mga kaldero at kawali
__________

Justification:
 Photo evidence refer to Appendix photos 3 and 8
F. Pinagkukunan ng Tubig at Supply
Saan po kayo kumukuha ng tubig? Mineral water
Pag-aari _________ _________Nakiki-igib lamang
Iba pang pinag-kukunan, tukuyin:______________________________________
Ang inyo po bang tubig ay maaaring inumin ? _____ Oo _______hindi

G. Palikuran
______________Sariling Palikuran (one common cr) ___________Nakikigamit ng Palikuran
______________Hindi gumagamt ng Palikuran

Uri ng Palikuran:
_____De buhos __________Balot style
______De flush __________Iba pang paraan , tukuyin
______ Naghuhukay lamang
______Tinatapon/deretso sa estero

Kalinisan ng Palikuran: _________malinis __________madumi

Iba pang obserbasyon: _______________________________________________________

Justification:
 Photo evidence refer to Appendix photo 12
  
H. Pagtatapon ng basura
_______________kinukolekta ng trak ng basura (araw-araw ; segregated) ____________ibinabaon
________________ sinusunog Ibang paraan, tukuyin: ______________________
________________nirerecycle

Justification:
 Photo evidence refer to Appendix photo 13 & 14

I. Drainage system:

1. San po dumadaloy ang tubig na ginagamit sa kabahayan?

_________ ilog
__________diretso sa kanal
__________ sa bukid
__________ sa estero
___________Iba pa, tukuyin

Isalarawan ang “Environmental Condition“ ng dinadaluyan ng tubig (Kung makikita ito ):

 Open canal in front of the house
 Water drainage is clogged that can easily cause flood

Justification:
 Photo evidence refer to Appendix photos 6 & 7

2. Uri ng Kapitbahayan
__________masikip o congested
__________ iskwater o slum

Justification:
 Photo evidence refer to: Appendix photo 15

a.) Kamusta naman po ang mga kapitbahay niyo? 
Maingay po ba o tahimik?
- Maingay at magulo noon, marami kasing nagvvideoke at nag iinuman pero ngayon maayos na
dahil bawal na ang videoke at inuman pag 10pm na.
b.) Dito po ba sa barangay niyo, may mga kaso po bana nagkakagulo o 
wala naman po?
  - Madalas noon may mga habulan pero sa may labasan lang.
- Mayroon ding curfew 10:00pm para sa 17 pababa.
Justification:
 Photo evidence refer to Appendix photo 16

3.Sosyal at Pangkalusugan na mga Pasilidad na mayroon sa inyong komunidad

Anu- ano mga pasilidad ang mayroon sa inyong komunidad?
____ health centers (2 minutes walk)
____ barangay hall (3 minutes walk) ___ ospital (10 minutes jeep)
____ paaralan (3 minutes walk) ___ botika (7 minutes walk)
 ____ palengke ___ klinika (pribado) (5 minutes walk)
____ bakery (2 minutes walk)
_____bumbero
_____bangko (2 minutes walk)
______department stores

Iba pa, tukuyin; ____________________________________________________________________

Justification:
 Photo evidence refer to Appendix photos 17-21

4. Pasilidad pang Komunikasyon at Transportasyon na mayroon sa inyong komunidad?

___________teleponon
___________computer shops
___________cable (TV)
___________Cable (internet)
Iba pa, tukuyin:megaphone (used by barangay for announcement)

Mga nagagamit na transportasyon sa inyong komunidad?

______Dyip
_______Kotse
_______Taxi
_______Tricycle
_______Side -car ( Sikad)
_______Motorsiklo
Iba pa, tukuyin: Bus, Grab, E-bike, LRT

D. HEALTH STATUS OF EACH FAMILY MEMBER

1) Medical and Nursing History (current and past)

Pangalan Posisyon sa Kasalukuyang Sakit Mga mahahalagang sakit na

Pamilya (Ama, (Current dinanas nung mga nagdaang
ina, anak, etc.) medical/nursing history panahon (past history of
of illnesses). significant Illnesses)
1. Mother M.J.P Mother N/A N/A
2. Father J.O Father N/A Abdominal Pain
3. Daughter J.O Daughter N/A Coughs and Colds
4. Son G.O Son N/A Dislocated Bone
5. Daughter J.O Daughter N/A Allergy (sea foods)
6. Grandmother N.P Grandmother Hypertension Hypertension
7. Grandfather A.P Grandfather Blood clot in the eye Hypertension
8. Sister-in-law J.C Sister-in-law N/A N/A
9. Brother A.C Brother N/A Diarrhea
10. Nephew A.D.C Nephew Colds Coughs and Colds
11. Niece N.L.C Niece Colds Coughs and Colds
12. Brother R.P Brother Deceased Kidney failure & Hypertension
13. Sister-in-law I.P Sister-in-law N/A Myoma & thick lining of the
mattress
14. Nephew C.L.P Nephew N/A Coughs and Colds
15. Nephew C.P Nephew Hypertension High Cholesterol &
Hypertension
 16. Nephew P.P Nephew N/A N/A
17. Nephew R.P Nephew N/A N/A
18. Niece P.P Niece N/A Colds
19. Nephew C.P Nephew N/A Fever

a) Mayroon po ba kayong mga paniniwala o isinasagawang mga “practices” na may kaugnayan sa kalusugan
o tuwing may nagkakasakit sa pamilya ( Hal. : Pagkonsulta sa doktor ,pagkonsulta sa albularyo, nagpapahilot,
nagpapatawas, di pagligo pag may sakit, at iba pa) ?____meron ____wala
Kung mayroon, anu -anu ito: Albularyo or Faith healer.

2. Nutritional assessment
Anthropometric measurement
Name of Age Sex Wt Ht. Mid-upper Body Mass Waist Circumfe- Hip WaistHip
Children . arm Index(BMI rence circumferen Ratio
(5 yrs. circumferenc ) ce
and e
below)
1. Naila 10 F 8kg 27 16cm 17.02kg/m 37.3 cm 45 cm 0.82 cm
Louis months . inch ^2
Cabral es

Interpretation:
Normal value- A BMI below 18.5 is considered underweight. A BMI of 18.5 to 24.9 is considered healthy. A
BMI of 25 to 29.9 is considered overweight. A BMI of 30 or higher is considered obese.
WC= obesity 90 cm for men 80 for women
Waist hip Ratio= waist circumference in cm./ hip circumference in cm
*central obesity-WHR is equal or greater than 1.0cm in men and 0.85 in women

Client status interpretation:

BMI – 17.02 kg/m^2 (underweight)
WHR – 0.82 cm (normal)

3.) Dietary History

24 hour Dietary Recall / Member of the Family:

Pangalan ng Miyembro Posisyon sa Uri ng Kinakain Dami ng Kinain

ng Pamilya Pamilya(Ama,
Ina, anak,etc.)

1. Mother M.J.P Mother Breakfast: Kare-kare with Boiled Breakfast: 2 servings of

rice kare-kare ; 2 servings of
Lunch: Pritong bangus with boiled rice
rice Lunch: 1 serving of
Dinner: Miswa with boiled rice pritong bangus ; 2
servings of rice
Dinner: 2 servings of
miswa ; 2 servings of
rice
2. Father J.O Father Breakfast: Kare-kare with Boiled Breakfast: 3 servings of
rice kare-kare ; 4 servings of
Lunch: Pritong bangus with boiled rice
 rice Lunch: 1 serving of
Dinner: Miswa with boiled rice pritong bangus ; 4
servings of rice
Dinner: 3 servings of
miswa ; 4 servings of
rice

3. Daughter J.O Daughter Breakfast: Kare-kare with Boiled Breakfast: 2 servings of

rice kare-kare ; 2 servings of
Lunch: Pritong bangus with boiled rice
rice Lunch: 1 serving of
Dinner: Miswa with boiled rice pritong bangus ; 2
servings of rice
Dinner: 2 servings of
miswa ; 2 servings of
rice

4. Son G.O Son Breakfast: Kare-kare with Boiled Breakfast: 2 servings of

rice kare-kare ; 3 servings of
Lunch: Pritong bangus with boiled rice
rice Lunch: 1 serving of
Dinner: Miswa with boiled rice pritong bangus ; 3
servings of rice
Dinner: 2 servings of
miswa ; 3 servings of
rice

5. Daughter J.O Daughter Breakfast: Kare-kare with Boiled Breakfast: 1 serving of

rice kare-kare ; 1 serving of
Lunch: Pritong bangus with boiled rice
rice Lunch: 1 serving of
Dinner: Miswa with boiled rice pritong bangus ; 1
serving of rice
Dinner: 1 serving of
miswa ; 1 serving of rice

6. Grandmother N.P Grandmother Breakfast: Kare-kare with Boiled Breakfast: 1 serving of

rice kare-kare ; 1 serving of
Lunch: Pritong bangus with boiled rice
rice Lunch: 1 serving of
Dinner: Miswa with boiled rice pritong bangus ; 1
serving of rice
Dinner: 1 serving of
miswa ; 1 serving of rice

7. Grandfather A.P Grandfather Breakfast: Kare-kare with Boiled Breakfast: 1 serving of

rice kare-kare ; 1 serving of
Lunch: Pritong bangus with boiled rice
rice Lunch: 1 serving of
Dinner: Miswa with boiled rice pritong bangus ; 1
serving of rice
Dinner: 1 serving of
miswa ; 1 serving of rice

8. Sister-in-law J.C Sister-in-law Breakfast: Kare-kare with Boiled Breakfast: 2 servings of

rice kare-kare ; 2 servings of
Lunch: Pritong bangus with boiled rice
rice Lunch: 1 serving of
 Dinner: Miswa with boiled rice pritong bangus ; 2
servings of rice
Dinner: 2 servings of
miswa ; 2 servings of
rice

9. Brother A.C Brother Breakfast: Kare-kare with Boiled Breakfast: 3 servings of

rice kare-kare ; 4 servings of
Lunch: Pritong bangus with boiled rice
rice Lunch: 1 serving of
Dinner: Miswa with boiled rice pritong bangus ; 4
servings of rice
Dinner: 3 servings of
miswa ; 4 servings of
rice

10. Nephew A.D.C Nephew Breakfast: Kare-kare with Boiled Breakfast: 1/2 serving of
rice kare-kare ; 1/2 serving
Lunch: Pritong bangus with boiled of rice
rice Lunch: 1/2 serving of
Dinner: Miswa with boiled rice pritong bangus ; 1/2
serving of rice
Dinner: 1/2 serving of
miswa ; 1/2 serving of
rice

11. Niece N.L.C Niece Breakfast: Cerelac Breakfast: 1 serving of

Lunch: Lugaw cerelac
Lunch: ½ serving of
Lugaw

12. Sister-in-law I.P Sister-in-law Breakfast: Kare-kare with Boiled
rice
Lunch: Pritong bangus with boiled
rice
Dinner: Miswa with boiled rice
Breakfast: 2 servings of
kare-kare ; 2 servings of
rice
Lunch: 1 serving of
pritong bangus ; 2
servings of rice
Dinner: 2 servings of
miswa ; 2 servings of
rice

13. Nephew C.L.P Nephew Breakfast: Kare-kare with Boiled Breakfast: 3 servings of
rice kare-kare ; 4 servings of
Lunch: Pritong bangus with boiled rice
rice Lunch: 1 serving of
Dinner: Miswa with boiled rice pritong bangus ; 4
servings of rice
Dinner: 3 servings of
miswa ; 4 servings of
rice

14. Nephew C.P Nephew Breakfast: Kare-kare with Boiled Breakfast: 3 servings of
rice kare-kare ; 4 servings of
Lunch: Pritong bangus with boiled rice
rice Lunch: 1 serving of
Dinner: Miswa with boiled rice pritong bangus ; 4
servings of rice
 Dinner: 3 servings of
miswa ; 4 servings of
rice

15. Nephew P.P Nephew Breakfast: Kare-kare with Boiled Breakfast: 3 servings of
rice kare-kare ; 4 servings of
Lunch: Pritong bangus with boiled rice
rice Lunch: 1 serving of
Dinner: Miswa with boiled rice pritong bangus ; 4
servings of rice
Dinner: 3 servings of
miswa ; 4 servings of
rice

16. Nephew R.P Nephew Breakfast: Kare-kare with Boiled Breakfast: 3 servings of
rice kare-kare ; 4 servings of
Lunch: Pritong bangus with boiled rice
rice Lunch: 1 serving of
Dinner: Miswa with boiled rice pritong bangus ; 4
servings of rice
Dinner: 3 servings of
miswa ; 4 servings of
rice

17. Niece P.P Niece Breakfast: Kare-kare with Boiled Breakfast: 1 serving of
rice kare-kare ; 1 serving of
Lunch: Pritong bangus with boiled rice
rice Lunch: 1 serving of
Dinner: Miswa with boiled rice pritong bangus ; 1
serving of rice
Dinner: 1 serving of
miswa ; 1 serving of rice

18. Nephew C.P Nephew Breakfast: Kare-kare with Boiled Breakfast: 2 servings of
rice kare-kare ; 2 servings of
Lunch: Pritong bangus with boiled rice
rice Lunch: 1 serving of
Dinner: Miswa with boiled rice pritong bangus ; 2
servings of rice
Dinner: 2 servings of
miswa ; 2 servings of
rice

4.) Eating/feeding habits/practices

1. Mayroon bang mga nakasanayang “practices “na sinasagawa na may kaugnayan sa pagpapakain sa
mga miyembro ng pamilya ( Hal,: Pagpapasuso ng pinag hugasan ng bigas (am) sa sanggol, hindi pagkain
ng baboy seafoods, vegetarian ang ilang miyembro ng pamilya at iba pa.)

Kung mayroon, anu-anu ang mga ito:

- Mahilig sa fried foods at bawal ang sea foods para dun sa may allergy.

- They love eating fried foods and sea foods are not allowed for those who have allergy.

2. Developmental Assessment of Infant, Toddler / Preschoolers:

 (Pagsasagawa ng MMDST at ipresenta ang resulta nito:______________________________

3. Risk factors assessment indicating presence of major and contributing modifiable risk factors for specific
lifestyle diseases. Check the table below if the client has its specific lifestyle diseases given in the table

4. Physical assessment findings indicating presence of illness state (whether diagnosed or undiagnosed by
medical practitioners).

Miyembro ng Pamilya na
may “Lifestyle Disease”
(Ama, Ina, anak,etc.)
1. Norma Pascua
2. Robert Pascua
3. Arnold Pascua
4. Charlon Pascua
Uri ng Lifestyle Disease Mga “modifiable Risk Factors “na maaring
High blood, Diabetes, Kanser, nagging dahilan ng nasabing Lifestyle Disease
COPD, etc.) (Hal.: Paninigarilyo, Pag-inom ng alak, Kawalan
ng ehersisyo, Stress, etc.)
Hypertension Stress and inadequate rest
Hypertension Smoking cigarettes
Hypertension Drinking alcohol
Hypertension Unhealthy diet

Justification:

 Photo evidence refer to Appendix photos 22, 23, 25, 26

Ipresenta ang mga resulta ng isinagawang “Physical Assessment sa Bawat Miyembro ng Pamilya at iba pang
naninirahan sa tahanan

 Ama:

 Ina:

 Lahat ng Anak na kasama sa Tahanan:

 Iba pang kasamang naninirahan sa Tahanan:

4. Results of laboratory, diagnostic or other screening procedures supportive of assessment findings.

Kung pahihintulutan , maaring hingin ang resulta kung may miyembro ng pamilya na sumailalim sa mga
eksaminasyon tulad ng X-ray ( anim na buwan na nakalipas at mayroong findings), eksaminasyon sa dugo, ihi
o dumi sa nakalipas na 2 linggo, anu pa mang uri ng “diagnostic procedures” ( ultrasound, CTscan,biopsy,
etc) . Ang mga ito ay makakatulong upang suportahan ang mga nakitang resulta ng siinagawang “Physical
Assessment”

E. VALUES, HABITS, PRACTICES ON HEALTH PROMOTION, MAINTENANCE AND DISEASE PREVENTION

1. Immunization Status of Family Members

Miyembro ng BCG HEPA- DPT Pentahib Polio AMV MMR Iba pang Bakuna,
Pamilya B (Anti- Tukuyin( Hal:
Measles (Measles,Mumps Pneumococcal,
and Rubella
Vaccine Flu vaccine,ect.)

1. Mother
/ / / / / / /
M.J.P

2. Father J.O / / / / / / /

3. Daughter / / / / / / /
J.O

4. Son G.O / / / / / / /

5. Daughter
/ / / / / / /
J.O

6.
Grandmother / / / / / / /
N.P

7.
Grandfather / / / / / / /
A.P

8. Sister-in-
/ / / / / / /
law J.C

9. Brother A.C / / / / / / /

10. Nephew
/ / / / / / /
A.D.C

11. Niece
/ / / / / /
N.L.C

12. Brother
/ / / / / / /
R.P

13. Sister-in-
/ / / / / / /
law I.P

14. Nephew
/ / / / / / /
C.L.P

15. Nephew
/ / / / / / /
C.P

16. Nephew
/ / / / / / /
P.P

17. Nephew
/ / / / / / /
R.P

18. Niece P.P / / / / / / /

19. Nephew
/ / / / / / /
C.P

Justification:

 Photo evidence refer to Appendix photo 28

1. Healthy Lifestyle Practices, Specify:

 a.) Anu-ano po ang mga bagay na inyong ginagawa upang mapanatiling malusog ang inyong mga katawan
bilang isang pamilya?
_________pagkain ng masustansya (fruits and vegetables)
__________pag -inum ng bitamina (enervon, mx-3)
__________ pag- iwas sa pag-inum ng alak
__________ pag-eehersisyo (jogging and Zumba)
___________pag-iwas sa paninigarilyo
___________pagkakaroon ng sapat na tulog
Iba pa, tukuyin:
- Maligo araw-araw, pagiging malinis sa katawan, pagpapalit ng damit, paghuhugas ng kamay.
- Take a bath every day, being clean on the body, changing clothes every day, hand-washing.

2. Adequacy of the ff. a.) rest and sleep, b.) exercise/activities, c.) use of protective measures, d) relaxation and
other stress management activities, e.) opportunities which enhance self-worth, and self-efficacy and sense of c
ness to self, others and a higher power, meaningfulness

Sabihin kung sapat ang mga sumusunod na Gawain:

Pagtulog : ______sapat _____kulang
Pamamahinga: ______sapat _____kulang
Ehersisyo: _____sapat _____kulang
Gawain: _____sapat _____kulang
Paggamit ng proteksyon (Hal. Kulambo, insect repelant, tsinelas):______sapat ______kulang
Relaksyon o Gawaing pangtanggal Stress: ________sapat ________kulang
Opurtunidad upang mapalawig ang tiwala sa sarili, kahalagahan ng sarili, pagiging epektibo at pagkakaroon ng m
pakikitungo sa ibang tao at sa sarili upang magroon ng mas mataas na pagkilala sa kakayahan at sarili
_______sapat _________kulang

3. Use of promotive preventive health services and use of healthy lifestyle - related services.

Alin sa mga sumusunod na serbisyo o programa ang inyong sinasagawa upang manatiling malusog at makaiwas

________pagkonsulta sa health center

_______ pagpapabakuna
_______ pinatitmibang ang mga anak
_______sumasali sa mga health teaching sa center o barangay
________nakikilahok sa mga lifestyle-related services (Zumba, smoking cessation programs, etc.)
________nakikilahok sa mga feeding programs
Iba pa, Tukuyin: ________________________________________________________________________
_______________________________________________________________________________