LEVEL & BLOCK

NO.

WESLEYAN UNIVERSITY-PHILIPPINES
COLLEGE OF NURSING
COMMUNITY HEALTH NURSING 1
FAMILY ASSESSMENT DATA CONSOLIDATION

A. TOTAL NUMBER OF CHN

STUDENTS(BLOCK)

B. TOTAL NUMBER OF FAMILY SURVEYED

C. TOTAL COMMUNITY POPULATION

D. TOTAL NUMBER OF HOUSES SURVEYED

I.DEMOGRAPHIC DATA

I.I AGE AND SEX DISTRIBUTION OF POPULATION

AGE MALE FEMALE TOTAL

GROUP NO. % NO. % NO. %

0-1

1-4

5-11

12-17

18-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-above

TOTAL 100% 100% 100%

I.2 GENDER DISTRIBUTION

GENDER GROUP 1 GROUP 2 GROUP 3 GROUP 4 TOTAL %

MALE %

FEMALE %

TOTAL 100 %
I.3 CIVIL STATUS

CIVIL STATUS MALE FEMALE TOTAL

NO. % NO. % NO. %

NEWBORN/INFANT (0-11 MOS)

CHILD (1-12 YEARS OLD)

SINGLE (13 Y/O AND ABOVE)

LEGALLY MARRIED

WIDOWED

SEPARATED

COMMON LAW/ LIVE IN

SINGLE PARENT

TOTAL % % 100 %

I.4 POSITION IN THE FAMILY

GROUP 1 GROUP 2 GROUP 3 GROUP 4 TOTAL %

1. HEAD OF THE
HOUSEHOLD

2. SPOUSE OF THE
HEAD OF THE
HOUSEHOLD

3. DEPENDENT

4. COHABITING

OVERALL TOTAL = 100 %

I.5 EDUCATIONAL ATTAINMENT

GROUP 1 GROUP 2 GROUP 3 GROUP 4 TOTAL %

1. GRADE 12 OR LESS

2. HIGHSCHOOL
GRADUATE

3. COLLEGE LEVEL

4. ASSOCIATE DEGREE

5. BACHELOR’S
DEGREE

6. POST-GRAUDATE
DEGREE
 OVERALL TOTAL = 100 %

I.6 OCCUPATION

TYPE OF WORKER GROUP 1 GROUP 2 GROUP 3 GROUP 4 TOTAL %

GOLD COLLAR

WORKER

WHITE COLLAR

WORKER

BLUE COLLAR

WORKER

NEW COLLAR

WORKER

OVERALL TOTAL = 100 %

II. FAMILY CHARACTERISTICS

TYPE OF FAMILY STRUCTURE

GROUP 1 GROUP 2 GROUP 3 GROUP 4 TOTAL %

1. Nuclear family IIII-II (7)

2. Extended family III (3)

3. Single parent family

4. Childless family

5. Step family

6. Grandparent family

7. OTHERS

OVERALL TOTAL = 100 %

III. GENERAL FAMILY RELATIONSHIP/DYNAMICS

1.1 HOME AND ENVIRONMENT

GROUP GROUP GROUP GROUP TOTAL %

1 2 3 4

1. Observable With conflict II (2)

conflicts between
family members
Without conflict IIII-III
(8)

TOTAL = 100%

2. Characteristics of Negative II (2)

communication
characteristic
 Positive IIII-III
(8)
characteristic

TOTAL = 100%

3. Interaction Negative II (2)

patterns among interaction
members
Positive interaction IIII-III
(8)

OVERALL TOTAL = 100%

IV FAMILY DIETARY HABITS

24 HOUR DIETARY RECALL

What did you eat yesterday?

BREAKFAST LUNCH DINNER TOTA %

L

GROUP GROUP GROUP

1 2 3 4 1 2 3 4 1 2 3 4

UNHEALTHY IIII II II
(4) (2) (2)

MOSTLY I I II
HEALTHY (1) (1) (2)

HEALTHY IIII- IIII- IIII-

(5) II I
(7) (6)

OVERALL TOTAL = 100 %

V. MONTHLY FAMILY INCOME SOURCE

I.I FAMILY INCOME SOURCE

TYPE OF WORKER GROUP 1 GROUP 2 GROUP 3 GROUP 4 TOTAL %

GOLD COLLAR

WORKER

WHITE COLLAR

WORKER

BLUE COLLAR

WORKER

NEW COLLAR

WORKER

OVERALL TOTAL = 100 %

 I.2 AVERAGE MONTHLY FAMILY INCOME

GROUP 1 GROUP 2 GROUP 3 GROUP 4 TOTAL %

LESS THAN P 5,000

5,000.00 – 10,000

10,000 – 15,000

15,000 – 20,000

20,000 – 30,000

30,000 – 40,000

40, 000 – 50,000

MORE THAN 50,000

OVERALL TOTAL = 100 %

VI. HEALTH STATUS/HEALTH HISTORY

HEALTH STATUS/HEALTH HISTORY

Reference: Morbidity rate of leading diseases in the Philippines ( 2019)

GROUP 1 GROUP 2 GROUP 3 GROUP 4 TOTA %

L

1. Acute upper respiratory

infection

2. Hypertension

3. Urinary tract infection

4. Acute lower respiratory tract

infection and pneumonia

5. Acute watery diarrhea

6. Skin disease

7. Animal bites

8. Bronchitis

9. Influenza

10. *COVID 19

11. OTHERS

*not included in the list for 2019 per DOH OVERALL TOTAL = 100 %
VII. FELT FAMILY NEEDS

FELT FAMILY NEEDS

(RANK ACCORDING TO CLIENTS RESPONSE. MOST REPEATED RESPONSE SHOULD BE RANKED

No. 1)

GROUP 1

RANK FELT NEED NO. OF RESPONSES

GROUP 2

RANK FELT NEED NO. OF RESPONSES

GROUP 3

RANK FELT NEED NO. OF RESPONSES

GROUP 4

RANK FELT NEED NO. OF RESPONSES

VIII. HOME AND ENVIRONMENT

1.1 HOME AND ENVIRONMENT

GROUP GROUP GROUP GROUP TOTAL %

1 2 3 4

1. LAND OWNED
 OWNERSHIP NOT OWNED

TOTAL = 100%

2. HOUSE OWNED
OWNERSHIP
NOT OWNED

TOTAL = 100%

3. ADEQUACY ADEQUATE
OF LIVING
SPACE INADEQUATE

OVERALL TOTAL = 100%

I.2 HOME AND ENVIRONMENT:

TYPE OF HOUSING MATERIAL

GROUP 1 GROUP 2 GROUP 3 GROUP 4 TOTAL %

a. Wood

b. Concrete

c. mixed

d. makeshift

e. others (specify)

OVERALL TOTAL = 100%

I.3 HOME AND ENVIRONMENT:

APPLIANCES OWNED

GROUP 1 GROUP 2 GROUP 3 GROUP 4 TOTAL %

a. Television

b. Refrigerator/freezer

c. Washing machine

d. Electric fan

e. Rice cooker

f. Radios

g. others

OVERALL TOTAL = 100%

I.4 HOME AND ENVIRONMENT:

TYPE OF GARBAGE DISOSAL

GROUP 1 GROUP 2 GROUP 3 GROUP 4 TOTAL %

a. Collected

b. Waste segregation

c. Feeding to animals

d. Open dumping
e. burning

f. burying

g. throw in the river/sewer

h. others (specify)

OVERALL TOTAL = 100%

I.5 HOME AND ENVIRONMENT:

TYPE OF TOILET FACILTY

GROUP 1 GROUP 2 GROUP 3 GROUP 4 TOTAL %

a. flush

b. wrap and throw

c. water sealed

d. pit privy

e. others (specify)

OVERALL TOTAL = 100%

I.6 HOME AND ENVIRONMENT:

TYPE OF DRAINAGE SYSTEM

GROUP 1 GROUP 2 GROUP 3 GROUP 4 TOTAL %

a. OPEN

b. CLOSE

OVERALL TOTAL = 100%

I.7 HOME AND ENVIRONMENT:

SOURCE OF WATER SUPPLY

GROUP 1 GROUP 2 GROUP 3 GROUP 4 TOTAL %

a. Owned

b. bought

c. shared

d. others (specify)

OVERALL TOTAL = 100%

I.8 HOME AND ENVIRONMENT:

DRINKING WATER STORAGE

GROUP 1 GROUP 2 GROUP 3 GROUP 4 TOTAL %

a. Refrigerated

b. Covered

c. uncovered

OVERALL TOTAL = 100%

I.9 HOME AND ENVIRONMENT:

CONTAINERS USED FOR WATER STORAGE

GROUP 1 GROUP 2 GROUP 3 GROUP 4 TOTAL %

a. Plastic pitcher

b. Bottles

c. Jar, clay pots

d. Others (specify)

OVERALL TOTAL = 100%

I.I0 HOME AND ENVIRONMENT:

COOKING FACILITIES

GROUP 1 GROUP 2 GROUP 3 GROUP 4 TOTAL %

a. Gas stove

b. Electric stove

c. charcoal

d. wood

e. Others (specify)

OVERALL TOTAL = 100%

I.II HOME AND ENVIRONMENT:

COMMON PEST AT HOME

GROUP 1 GROUP 2 GROUP 3 GROUP 4 TOTAL %

a. Ants

b. Flies

c. Bed bugs

d. Rats

e. Termites

f. Mice

g. cockroaches

h. Others (specify)

OVERALL TOTAL = 100%

I.I2 HOME AND ENVIRONMENT:

WITH BREEDING SITES OF THESE PETS SEEN AT HOME

GROUP 1 GROUP 2 GROUP 3 GROUP 4 TOTAL %

i. Ants

j. Flies
k. Bed bugs

l. Rats

m. Termites

n. Mice

o. cockroaches

p. Others (specify)

OVERALL TOTAL = 100%

I.I3 HOME AND ENVIRONMENT:

PETS/ANIMALS KEPT IN THE HOME/YARD

GROUP 1 GROUP 2 GROUP 3 GROUP 4 TOTAL %

a. Dogs

b. Cats

c. OTHERS

OVERALL TOTAL = 100%

I.I4 HOME AND ENVIRONMENT:

ACCIDENT HAZARDS PRESENT AT HOME

(Indicate as surveyed, choose only the 3 most hazardous per group)

GROUP 1 GROUP 2 GROUP 3 GROUP 4

1 1 1 1

2 2 2 2

3 3 3 3

IX. HEALTH AND HEALTH PRACTICES

I.I H&H P: COMMON ILLNESS SUFFERED IN THE LAST 6 MONTHS

GROUP 1 GROUP 2 GROUP 3 GROUP 4 TOTAL %

a. DIARRHEA AND
VOMITING

b. INFLUENZA (COUGH
AND COLD)

c. VIRAL FEVER

d. SORE EYES
e. DOG BITE

f. SKIN DISEASE

g. DENGUE

h. OTHERS

OVERALL TOTAL = 100%

I.2 H&H P: CONSULTATION OF HEALTH-RELATED PROBLEMS

(Whom do the family consult for health-related problems?)

GROUP 1 GROUP 2 GROUP 3 GROUP 4 TOTAL %

a. Manghihilot

b. Midwife

c. Doctor

d. Albularyo

e. Nurse

f. Others

OVERALL TOTAL = 100%

I.3 H&H P: CONSULTATION OF PROBLEMS OTHER THAN HEALTH

(For problems other than health, whom does the family consult?)

GROUP 1 GROUP 2 GROUP 3 GROUP 4 TOTAL %

a. Family members

b. Friends

c. Priest/ Church leader

d. Relatives

e. Barangay officials

f. Others (specify)

OVERALL TOTAL = 100%

I.4 H&H P: UNDER FIVE (0-59 mos.) IMMUNIZATION STATUS

National Immunization Program

GROUP 1 GROUP 2 GROUP 3 GROUP 4 TOTAL %

NONE

INCOMPLETE (on-going)

COMPLETE

OVERALL TOTAL = 100%

I.4a H&H P: COVID 19 IMMUNIZATION STATUS

5-11 years old

 GROUP 1 GROUP 2 GROUP 3 GROUP 4 TOTAL %

NONE

INCOMPLETE (on-going)

COMPLETE

OVERALL TOTAL = 100%

I.4b H&H P: COVID 19 IMMUNIZATION STATUS

12-17 years old

GROUP 1 GROUP 2 GROUP 3 GROUP 4 TOTAL %

NONE IIII-I (6)

INCOMPLETE (on-going) IIII- (5)

COMPLETE IIII-IIII-IIII-
IIII-IIII-IIII
(29)

OVERALL TOTAL = 100%

I.4c H&H P: COVID 19 IMMUNIZATION STATUS

18 years old and above

GROUP 1 GROUP 2 GROUP 3 GROUP 4 TOTAL %

NONE IIII-I (6)

INCOMPLETE (on-going) IIII- (5)

COMPLETE IIII-IIII-IIII-
IIII-IIII-IIII
(29)

OVERALL TOTAL = 100%

I.5 H&H P: PHYSICAL AND MENTAL HEALTH

Does the family have adequate- GROUP YES NO

a. Rest and sleep 1

b. Exercise 1

c. Relaxation activities 1
 2

d. Stress management activities 1

TOTAL YES= TOTAL NO=

OVERALL TOTAL =
(Y&N)

%+ % = 100%

X. ENVIRONMENT

I.I ENVIRONMENT

(Indicate entries in your survey tool)

GRP 1 GRP 2 GRP 3 GRP 4 TOTAL %

Kind of 1. URBAN IIII- (5)

neighborhood
2. POOR URBAN IIII (4)

3. RURAL IIII-
IIII-I
(11)

4 NO ANSWER II (2)
PROVIDED

5 POOR RURAL I (1)

OVERALL TOTAL = 100%

Social and health 1. BARANGAY IIII-

facilities available CENTER IIII-
IIIII-I
(16)

2. MUNICIPAL IIII (4)

HEALTH CENTER

3 PLAZA IIII-
CENTRO/MALL IIII-
(10)

4 IIII-IIII
HOSPITAL/CLINICS (9)

5 NO ANSWER II (2)
PROVIDED

OVERALL TOTAL = 100%

Communication 1. TERMINAL (JEEP, IIII-

and transportation TRICYCLE, BUS) IIII-
facilities IIII-
IIII-III
(23)

2 MOBILE PHONES II (2)

 3 PRIVATE II (2)
VEHICLE

5 NO ANSWER III (3)

PROVIDED

OVERALL TOTAL = 100%

I.2 AWARENESS OF COMMUNITY ORGANIZATION

Are members of the family aware of existing organizations in the community?

GROUP 1 GROUP 2 GROUP 3 GROUP 4 TOTAL %

AWARE

NOT
AWARE

OVERALL TOTAL = 100%

I.3 INVOLVEMENT IN COMMUNITY ORGANIZATION

Are members of the family involved in organizations in the community?

GROUP 1 GROUP 2 GROUP 3 GROUP 4 TOTAL %

INVOLVED

NOT
INVOLVED

OVERALL TOTAL = 100%

I.4 COMMUNITY ORGANIZATIONS

Indicate community organizations known by the members of the community

GROUP 1 GROUP 2 GROUP 3 GROUP 4

1 1 1 1

2 2 2 2

3 3 3 3

4 4 4 4

5 5 5 5

JGABAYANMSNRN2022