SCHOOL OF NURSING, ALLIED HEALTH,

AND BIOLOGICAL SCIENCES

BS NURSING PROGRAM

RELATIONSHIP OF THE FAMILY TO THE LARGER COMMUNITY: (Connect the family to the different aspects of the community using the legend
below in order to determine the family’s ability to maintain a reciprocal relationship with the community and to determine if the family is a
closed or open system.)
Strong connection

Church
Tenuous connection

Etc Stressful connection

Reciprocal direction of
energy & resources
Etc

No connection /
RHU/Hos participation (no line)

Male

Female

Social env’t of
family f amily

School

A.HOME AND ENVIRONMENT (Use OBSERVATION only as method of data gathering if at all possible. Supply data with words, X or
NA or not applicable. Do not leave any blank as this will mean not assessed. Blank spaces mean that the item has not yet been
assessed).
1) HOUSING Owned: Rented:
Total # of rooms of house: Approx size of each sleeping room (sq m):
NA # of people occupying each room:
Lighting: Electricity: Kerosene lamp: Rechargeable battery: Candle:
Others specify:
Ventilation: Specify how many windows does each room have:
Type of materials used:
Light (bamboo, nipa, etc): Mixed (combination of wood, GI, cement): Permanent/strong (cement):
Others (please specify):
Presence of breeding/resting places of vectors (roaches, flies, mosquitoes, rats, etc.): None observed:
Present: Location (pls specify kitchen, garbage inside the kitchen, etc.):
Kitchen: Generally clean surroundings: Generally unclean:
Pots and pans washed and kept in cupboards: Pots, pans, plates scattered and unclean
No flies/cockroaches/rats observed: Flies/cockroaches/rats visible
Food storage (check as many as applicable)
Refrigerator:
Food cabinets: closed: open:
Pot/food keepers/plastic containers: with cover: without cover:
None because all food is consumed every meal others (specify)
Presence of accident hazards (check as many as applicable)
Sharps unkept:
Medicine cabinet: Present: Absent:
With lock Where are medicines kept:
Without lock

Where are poisons kept:

Cooking facility: Gas range Gas stove Electric stove
If gas stove or gas range: With safety device: Without
“Dirty kitchen” With clean surroundings With piled garbage/combustible debris near it
Burning of food: Never occurred Seldom occurs Commonly occurs
Checking of stove before family members leave the house:

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 SCHOOL OF NURSING, ALLIED HEALTH,
AND BIOLOGICAL SCIENCES
BS NURSING PROGRAM

Not a practice Only a few members do this Consciously done by all members

Electrical wiring checked annually: Yes No

Attitude of members leaving sockets with plugs still connected: Yes No
Presence of stairs in the home: Yes None
If yes: with rails None but necessary Not necessary
Members walking barefoot:
When entering CR/bathroom: Yes No

When going outside the house: Yes No

Slippery floors: Present None
Domestic animals that bite: Present None
Highway in close proximity to the house: Yes No
Others (specify):
Water supply:
Source: Level I (protected spring, deep well) Level II Level III Others (specify)
Ownership: Family-owned Shared with other families How many families
Storage of drinking water (check as many as applicable):
Earthen jar: with cover without cover
Bottles / plastics: with cover without cover Water dispenser:
Others (specify): None
Storage of water used for cooking:
Water tank: with cover without cover
Drums: Plastic Tin drums Others (pls specify)
Adequacy: Frequency of delivery per week: Liters generated per minute:
Potability: Boiled Tested: Yes Not tested
If tested: When last tested Who did the test
Results of test:
Domestic animals
Type of animal Number Check appropriate column
With cage Stray
Dog
Fowl (specify)
Cat
Pig
Others (specify)
Toilet facility:
Type: Level I : Level II Level III:
If open pit privy, specify location and distance from the kitchen
Ownership: Family-owned Public
Shared with other families How many families:
Sanitary condition: No smell Foul-smelling With flies No flies
Garbage or refuse disposal:
Type: Landfill Composting Burying Burning
Open dumping Location and distance from the house: 50meters
Garbage collection Schedule of collection
Segregation of waste: Practiced by family Not practiced
Sanitary condition: No flies No smell With flies With smell
Drainage system: Type: Closed/blind Open None (directly to the ground)
Drainage continuously flow With stagnation of drainage
Sanitary condition: Frequented by vectors Not frequented by vectors
2) KIND OF NEIGHBORHOOD

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 SCHOOL OF NURSING, ALLIED HEALTH,
AND BIOLOGICAL SCIENCES
BS NURSING PROGRAM

Rural Rurban Urban Slum area

Distance of one house to another (approx in meters): Population density:
Conclusion: Congested Not congested

3) SOCIAL/RECREATIONAL AND GOVERNMENT FACILITIES

FACILITY CHECK IF DISTANCE FROM HOUSE FAMILY AWARENESS & UTILIZATION
PRESENT (approx in meters or kms) Check if family is Check if family
aware utilizes
Social / government facilities
Day Care / Nursery
Elementary school
High school
Vocational school
College
DSWD
DENR
Others (specify)
Recreational facilities
Sports center
Others (specify)
Non-government agencies servicing the comty

People’s organization present in the community

Park

4) HEALTH FACILITIES AND MANPOWER AVAILABLE

HEALTH FACILITY DISTANCE FROM HOUSE TYPE & # OF FAMILY AWARENESS & UTILIZATION
(approx in m or in kms) MANPOWER Check if family is Check if family
AVAILABLE aware utilizes
Barangay Health Station
Rural Health Unit
Emergency / District Hospital
Others (specify)

5) COMMUNICATION FACILITIES
Phones: mobile land phone radio TV computer
Letter word of mouth others (specify)

6) TRANSPORTATION FACILITIES ON A 24-HOUR BASIS: None Only hitch rides

Private car Taxi PUJ Van Tricycle Passenger bus

B. HEALTH STATUS OF EACH FAMILY MEMBER

 Obstetrical history
NAME OF CHILD AGE OF FREQUENCY OF PLACE OF DELIVERY TYPE OF REMARKS
(Listed by order of MOTHER PRENATAL CHECK Attendant at Just check if DELIVERY (NSVD, (Specify if alive or
arrangement in the WITH THIS UPS (eg: 1x every mo, Home hospital delivery LCCS, Assisted dead on
family) PREGNANCY 3x during whole delivery – specify assessment. If
pregnancy, etc) if with difficulty dead, specify
or none) reason)

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 SCHOOL OF NURSING, ALLIED HEALTH,
AND BIOLOGICAL SCIENCES
BS NURSING PROGRAM

 Family developmental stage: Aging Family.

 Expected tasks:
 Developmental assessment of infants, toddlers and preschoolers through the MMDST (separate assessment tool)
 Nutritional assessment of vulnerable family members (infants, children, pregnant, post-partum mothers, sick members & members with
clinical manifestations of thinness or undernourished)
VULNERABLE FAMILY WEIGHT HEIGHT MID-UPPER ARM FOOD PREFERENCES EATING/FEEDING
MEMBER CIRCUMFERENCE HABITS/PRACTICES
(for children only)

 Dietary history indicating quality and quantity of food intake per day:
CONTENT & AMOUNT BREAKFAST LUNCH SUPPER
Usual content of food
Amount of food intake (average)
Risk assessment measures for obese members of the family
MEASURE / INDICATOR EXPECTED NORMAL FINDINGS ACTUAL FINDINGS
OBESE FAM MEMBER FINDINGS
Body mass index (BMI = wt in kgs / ht in m2) 18.6 to 22.9
Waist circumference <90 cm for men; <80 cm for women
Waist-hip ratio (WHR = waist circumference in Less than 1 cm in men; less than .85
cm/ hip circumference in cm cm in women

 Assessment of common risk factors leading to non-communicable diseases (check as many as applicable)
RISK FACTOR CHECK THOSE NON-COMMUNICABLE DISEASES WHEREBY FAMILY MEMBER/S ARE PREDISPOSED OF
PRACTICED IN THE (pls check appropriate column)
FAMILY CVD DM CANCER RESP CONDITION
Alcohol intake
Blood glucose level, elevated
Blood lipids/cholesterol, elevated
Blood pressure, elevated
Family history of cancer, DM, HPN, etc
Inadequate fiber intake
Nutrition/diet, poor
Obesity
Physical inactivity
Sedentary life style
Smoking cigarette or tobacco
 Assessment of risk factors leading to common communicable diseases (check as many as applicable)
Possible risk factors Check as COMMUNICABLE DISEASE FOR WHICH FAMILY ARE PREDISPOSED OF
many risk (check as many as applicable)
factors PTB Other respiratory Dengue & other Diarrheal
present diseases mosquito-borne dis disease
Exposure to a suspect/registered TB case
Exposure to a respiratory-related CD
Lives in a known dengue-infected area
Does not regularly practice the following habits:
Changing H2O/scrubbing sides of flower vases
Not cleaning surroundings

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 SCHOOL OF NURSING, ALLIED HEALTH,
AND BIOLOGICAL SCIENCES
BS NURSING PROGRAM

Non-disposal or rubber tires, empty bottles & cans

Not keeping water containers covered
Too many hanging clothes inside the house
Poor environmental sanitation
Non-potable water supply
Unsanitary food sources, preparation and serving
Fond of eating street foods
Malnourished

 Focused assessment results of vulnerable family members indicating presence of illness states
Vulnerable Chief Family beliefs as Remedies done by family
member complaint to causes Medical consult to Home remedies Remarks
whom/where initiated

 Medical and nursing history indicating current or past significant illnesses or beliefs and practices conducive to health and
illness
Family member Past illness Beliefs as to causes Remedies done by family
Home Hosp / consult Remarks

 Results of laboratory/diagnostic or screening procedures undergone by vulnerable family members

Family member Laboratory/diagnostic/screening procedure
Procedure done Expected normal findings Actual findings
None
None

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

 BELIEFS AND PRACTICES OF PROMOTIVE & PREVENTIVE HEALTH SERVICES
 Immunization status of family members, especially children 0-8 years old and mothers of reproductive age (14-49 years old)
FAMILY MEMBERS BCG HBV OPV DPT AMV TT
1 2 3 1 2 3 1 2 3 1 2 3 4 5

 Reasons for submitting self or children for immunization:

 Regular check ups
Family member Age Promotive / preventive services
Never goes Goes only Goes for Does Annual Dental Annua Stool Testic
for check up for check annual month PAP’s exam = 1- l eye guiac ular
even if ill up if ill PA ly SBE smear 2x a year exam test exam

 Practice of family planning methods (applicable for married couples of reproductive age or MCRA = 14-49 years old)

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 SCHOOL OF NURSING, ALLIED HEALTH,
AND BIOLOGICAL SCIENCES
BS NURSING PROGRAM

FP acceptor: FP user: FP Non-acceptor

Method accepted: Method being used:
Reason for acceptance and use: none
Reason for non-acceptance / non-use:
Misconceptions heard about the use of FP:
 VALUES, HABITS AND PRACTICE OF OTHER HEALTH LIFE STYLES
 Exercise, rest and sleep
Family Rest and sleep Exercise Relaxation activities Stress
members # of hours Interrupted Naps Naps Nature of Frequ # of management
per night or present absent exercise ency minutes activities
continuous per per employed
week exercise

 Beliefs and practices about nutrition during menstruation, pregnancy, childbirth, illness, feeding babies, etc.
Menstruation:
Pregnancy:
Childbirth:
Feeding babies:
Illness:
Others:

Finalized by: Core Group on NCP and FNCP Formats, School of Nursing, October 2010

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