INITIAL DATA BASE ( For Children )

Name of Child: Boy EM Cribe Age: 3

I. CHARACTERS:
A. What is the type of family structures?
✔ Nuclear Patriarchal
Extended Matriarchal
B. Who makes decision regarding health care? May Ann Cribe ( Mother of Elisse )
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 - 7 - 8 hours
Nap during the day ✔
Do members sleep together - Yes
2. Eating pattern
How many meals each day? - 3 to 4 Meals a day ( including afternoon snacks/merienda)
Does appears overweight? - No
Does appears underweight? - No
3. Leisure time activities
How does each member spend leisure hours? - Watching cartoon and Disney movies
Is it appropriate for the sex and age group? - Yes
What is the effect to the family? - Spending more quality and happy hours

II. FAMILY INFORMATION

Head of the family: Elvis June Cribe
Address: Block 40 J lot30 phase 1, Longos, Malabon City
Members of the household: 4

NAME RELATIONSHIP AGE EDUCATIONAL ATTAINMENT

EJ Cribe Father 45 N/A
MA Cribe Mother 39 N/A
EN Cribe Sibling 1 N/A

III. SOCIO-ECONOMIC AND CULTURAL FACTORS

A. Income

NAME OCCUPATION PLACE INCOME ( MONTHLY )

EJ Cribe Rigger Pasay City 30,000

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

✔ Yes No
2. Who makes decisions regarding money matters? Elvis June Cribe ( Father )
3. Religious affiliation: Catholic

IV. ENVIRONMENTAL FACTORS

 A. Housing
1. Ownership
Owned ✔ Rented Rent-Free
2. Construction materials used
Light ✔ Mixed Strong
3. Living space
✔ Adequate Inadequate
4. Adequacy in furniture
✔ Adequate Inadequate
5. Water source
✔ Private Public
6. Food storage
✔ Refrigerator Jars/container
7. Cooking facility
Electric stove Firewood
✔ Gas Stove Kerosene
8. Drainage facility
Open drainage ✔ Blind drainage None
9. Toilet facilities/type
✔ Flushed Over hung latrine
Bored-hole latrine Water-sealed latrine
Pail system None
10. Sanitary condition
Fair ✔ Good Poor
11. Neighborhood
Congested Slum ✔ Other
12. Availability of Health Care Facility
Describe briefly: There’s some clinic and government hospital inside the municipalities that can be
access easily even without transportation vehicle.
13. Garbage disposal
Dumped at street corner ✔ Picked up by garbage collector
Buried Burned then buried

V. HEALTH MEDICAL HISTORY

NAME PAST ILLNESS ILLNESS STATE HEALTH ACTION TAKEN
Elisse Jade Cribe Common Cold Not severe Visiting Health Care center

VI. VALUE PLACED ON PREVENTION OF DISEASE

NAME AGE COMPLETE
Elisse Jade Cribe 3 Chicken Fox ( Varicella ) ✔
Measles ✔
Influenza ( Flu ) ✔

Preventive practices employed by the family: Ensuring environment are being cleaned once a week

Sources of Health Care:

✔ Health Center ✔ Government Hospital
 Private Hospital ✔ Others

DOCUMENTATION

Before the interview starts, I make sure that I had already established rapport to both mother and
her child and to other family members inside their house so that she can easily provide all of the
important questions that I needed to asked for data completion and also to make them more
comfortable throughout the whole interview.

Furthermore, I made myself clear and had an agreement with them that all of the following data
that I’ve gathered for this data base will stay confidential between me and my clinical instructor to
ensure their safety especially the child.