INITIAL DATA BASE

I. CHARACTERS:
A. What is the type of family structures?
______ Nuclear _______ Patriarchal
______ Extended _______ Matriarchal
B. Who makes decision regarding health care? _____________________
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 _____________
Nap during the day __________________
Do members sleep together ___________
2. Eating pattern
How many meals each day? ___________
Who appears overweight? ____________
Who appears underweight? ___________
3. Leisure time activities
How does each member spend leisure hours? ____________________________
Is it appropriate for the sex and age group? ______________________________
What is the effect to the family? _______________________________________
Any joint activity for leisure? __________________________________________

II. FAMILY INFORMATION

Head of the family: _________________________
Address: _________________________________
Members of the household: __________________

NAME RELATIONSHIP AGE EDUCATIONAL ATTAINMENT

III. SOCIO-ECONOMIC AND CULTURAL FACTORS
A. Income

NAME OCCUPATION PLACE INCOME

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

________ Yes _____ No
2. Who makes decisions regarding money matters? _____________________
3. Religious affiliation: ___________________________
4. What roles does the family play in the community? ___________________

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: _____________________________
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: _____________________________________________________
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

VI. VALUE PLACED ON PREVENTION OF DISEASE

NAME AGE COMPLETE INCOMPLETE

Preventive practices employed by the family: _________________________

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

Scale for Ranking Health Problems According to Priorities

CRITERIA WEIGHT
1. Nature of the problem
Scale: Health Threat 2 1
Health Deficit 3
Foreseable Crisis 1
2. Modifiability of the problem
Scale: Easily Modifiable 2 2
Partially Modifiable 1
Not Modifiable 0
3. Preventive potential
Scale: High 3 1
Moderate 2
Low 1
4. Salience
Scale: A serious problem, immediate attention needed 2 1
A problem but not needing immediate attention 1
Not a felt/need problem 0
Scoring

1. Decide on score for each criteria

2. Drive the score by the highest possible score and multiply by weight
Score X Weight
Highest Score
3. Sum up the scores for all criteria. The highest score is 5, equivalent to the total weight