COLLEGE OF NURSING

1ST Semester S.Y. 2022 - 2023

NCM104
COMMUNITY HEALTH NURSING I
Individual / Family
Initial Data Base

I. Family Information
Head of the Family: _______________________________ Date of Birth: ______________________ Gender: ____________ Age: _______ Civil Status:
____________
Religion: ____________________ Education: _________________ Occupation: __________________ Workplace: _________________ Monthly Income:
___________
Address: __________________________________________________________________________________________ Residency: _____ Permanent
_____ Migrant
The person who decides for the family as a whole: ___________________________________________________
The person who decides for the family in terms of health issues: __________________________________________________
II. Family Members (Still Alive)
Name Relation Gender Age/ Date of Civil Status Studying School Educational Occupation Monthly Income
Birth Yes/ No Attainment
1
2
3
4
5
6
7
8
9
10
 _____ latern
_____ candle
III. House and Environment
a. House and Lot _____ Others, please specify: _____________
1. Lot:
_____ Owned 6. Source of fire (for cooking):
_____ Rent _____ electric
_____ Others, please specify: _________
2. House: _____ LPG
_____ Owned _____ Gas
_____ Rent
_____ Living with another family _____ wood
Bilang ng Kwarto: ____________ Sukat: _____________ _____ coal
3. House materials:
7. Bathroom:
_____ Concrete
_____ water sealed
_____ Wood and concrete
_____ Buhos
_____ bamboo and nipa palm
_____ Antipolo
_____ Others, please specify: _____________
_____ Others, please specify: _____________
4. Water supply:
8. House Appliances:
_____ lake
_____ Computer
_____ waterworks
_____ TV
_____ private
_____ DVD Player
_____ water pump
_____ Refrigerator
_____ well
_____ Washing machine
_____ Others, please specify: _____________
_____ Electric fan
5. Source of light:
_____ Radio/ cassette
_____ electricity
_____ Others, please specify: _____________
_____ lamp
 9. Transportation _____ Chicken
_____ Car _____ Goat
_____ Jeepney _____ Others, please specify: _____________
_____ Truck 11. Garbage Disposal
_____ Motorcycle _____ Segregation
_____ Bicycle _____ Compost
_____ Tricycle _____ Garbage collection
10. Pets/Livestocks _____ Others, please specify: _____________
_____ Dog 12. Type of Drainage
_____ Cat _____ open drainage
_____ Pig _____ close drainage
_____ Cow

b. Type of Environment: ____________________________________

 1. How is the relationship of those living in the house? _______________________________________________
2. If there is a disagreement, what solution is being done? ____________________________________________
3. Who is the mediator if there is a disagreement within the house? _____________________________________
c. Different Institutions found in the Community
A. School: College: _____ Secondary/ High School: _____ Elementary: _____ Kindergarten: _____
Number of Teachers: ____________ Number of Students: ____________
Are the rooms enough for all the students? _______________________
B. Barangay Health Center: _____ Accessible _____ None
Types of Health worker that serves the people
_____ Doctor _____ Nurse _____ Midwife _____ BHW
Health Services:
_____ For pregnant women
_____ For healthy children
_____ For sick children
_____ For the elderly
_____ For those with heart disease
_____ For those with diabetes
_____ For those with high blood pressure
_____ For teaching family planning
_____ For teaching about nutrition
_____ For dental health
_____ Campaign for the environment
C. Barangay Hall: _____ Accessible _____ None
How is the leadership of the Chairman?
 ____________________________________________________________________________
What are the roles of individuals as part of the community?
____________________________________________________________________________
What are the platform that the Chairman is implementing in the community?
_____ Security
_____ Health
_____ Environment
_____ Education
_____ Climate
_____ Livelihood
_____ Culture and sports
_____ Industry and agriculture
_____ Nutrition
Are the people given a chance to give suggestions that can enhance the community?
____________________________________________________________________________
What are the changes in the community because of the Chairman’s leadership?
____________________________________________________________________________
What can you say regarding his/her leadership?
____________________________________________________________________________

D. Chapel/Church: _____ Available _____ None

 Is Sunday mass available weekly in your community and how many times do you go to church?
____________________________________________________________________________
E. Type of Communication within the Community
_____ Telephone _____ Poster _____ Cellphone _____ Announcements
IV. Health Status
1. What kinds of diseases have you and your family had experienced?
____________________________________________________________________
2. If someone from the family had been sick or was hospitalized, what is the cause?
____________________________________________________________________
3. Where did you and your family go to consult when someone in the family is feeling ill?
_____ Health Center
_____ Public Hospital
_____ Private Hospital
_____ Faith Healer
_____ Others, please specify: _____________
4. What type of medication do you use?
_____ Medication from the doctor
_____ Herbal medicine
_____ Self-medication
_____ Medicine from the Health center
_____ Others, please specify: _____________
5. Most common cause of illness
_____ Contaminated food and water
_____ Not enough knowledge about nutrition
_____ Sanitation
 _____ Climate change
_____ Others, please specify: _____________
6. Is anyone pregnant in the family?
____________________________________________________________________
7. How times has she gone through pregnancy?
____________________________________________________________________
8. What are the common problems women face during the pregnancy?
____________________________________________________________________
9. Where does she consult regarding the pregnancy?
____________________________________________________________________
10. Do you use any method of family planning?
____________________________________________________________________
11. What method of family planning is being used?
____________________________________________________________________
12. Is anyone in the family suffering from any type of disease and what disease is it?
____________________________________________________________________
____________________________________________________________________
13. What is the result from the laboratory?
____________________________________________________________________
14. Is anyone in the family mentally challenged?
____________________________________________________________________
15. How do you help this family member?

V.
A. Vaccine

Age (0-7 yrs. Vaccine Type of Baby Feeding

Name Height Weight
old)
BCG DPT OPV Measles Hepa B Breast Feeding Bottle Feeding Mix

B.
1. What do you do to have a healthy living and to prevent illness?
_____ Eating healthy everyday
_____ Getting enough sleep
_____ Exercise/ Physical Activities
_____ Relaxation
2. Ways to improve hygiene and to prevent illnesses.
_____ Proper handwashing
_____ Clean environment
_____ Proper garbage disposal
_____ Wearing mask
_____ Wearing gloves
 _____ Using umbrella to avoid direct contact with sun
_____ Others, please specify: ___________________________________________________________

References: Araceli. S. Maglaya Nursing Practice in the Community 4 th Edition Chapter 2 pages 54-81
CHN I Form # 00