COLLEGE OF HEALTH SCIENCES

Notre Dame University

Cotabato City

INITIAL DATA BASE FOR FAMILY NURSING PRACTICE

Name of Student(s):

Clinical Instructor:

Area of Assignment Barangay/Street/Purok:

Surname of Family:

Contact number/s of the family:

Date of Visit:

A. FAMILY STRUCTURE, CHARACTERISTICS AND DYNAMICS

Name Birthday Sex Civil Educational Position in Living

(Age) Status Attainment the Family with
Family or
Not
 A.1 Type of family structure (e.g. matriarchal or patriarchal, nuclear or extended):

____________________________________________________________________

A.2 Dominant family member(s) in terms of decision-making, especially in matters of

health case:

____________________________________________________________________

A.3 General family relationship/dynamics (presence of any obvious/readily observable

conflict between members; characteristics communication/interaction patterns among

members):

____________________________________________________________________

____________________________________________________________________

B. SOCIO-ECONOMIC AND CULTURAL CHARACTERISTICS

Name Occupation Place of Monthly Educational Ethnic Religion

Work Income Attainment Affiliation

Total Monthly Income of the Family = _____________________________

 B.1 Breakdown of Expenses (Monthly)

______________________________________________ = P __________________

______________________________________________= __________________

______________________________________________= __________________

______________________________________________= __________________

______________________________________________= __________________

B.2 Adequacy to meet basic necessities (food, clothing, shelter):

_______________________________________________________________________

B.3 Who makes decision on money spending: __________________________________

B.4 Significant others (roles they play in family’s life: ___________________________

B.5 Relationship of the family to larger community (nature and extent of participation of

the family in community activities):

_______________________________________________________________________

C. HOME AND ENVIRONMENT

C.1 Types of house

A. Light material______ B. Concrete________ C. Half concrete________

C.2 House Ownership

A. Owner_________ B. Sharer________ C. Renter_________

C.3 Adequacy of living space: ______________________________________________________

C.4 Sleeping arrangement: ________________________________________________________

C. 5 Presence of breeding or resting sites of vectors of diseases (e.g mosquitos, flies, etc):

____________________________________________________________________________

C.6 Presence of accident hazards: __________________________________________

C.7 Food storage and cooking facilities:

Food storage (Please check)
Refrigerated _____________ Not refrigerated _______

Covered ________
Uncovered____________

Cooking facility (Please Check)

Electric stove__________ Gas stove____________ Firewood/ Charcoal________

C.8 Water supply (Source, ownership, portability): (Put a check.)

Level I – Point Source (Protected well or a developed spring) ______
Level II – Communal Faucet System or Stand posts (piped distribution) ________
Level III- Waterworks System or individual House connections _________

C.9 Toilet Facility (type, ownership, sanitary condition): (Please check)

Level 1- Non-water carriage (pit latrines, pour flush toilet) _______
Level 2- Water carriage (water sealed, flushed type with septic tank) ________
Level 3- Water carriage connected to septic tanks to a treatment tank _______

C.10 Garbage/refuse disposal (type and sanitary condition): (please check.)

Collected ________ Burial ______
Open burning ______ Dumping _______
Animal feeding (leftovers) _______

C.11 Drainage system (type, sanitary condition) _____________________________

C.12 Kind of neighborhood (e.g. congested, slum ) __________________________

C.13 Social and health facilities available __________________________________

C.14 Community and transportation facilities available ______________________

D. HEALTH STATUS OF EACH FAMILY MEMBER

Name Height Weight Body Mass Vital Signs Past Present
Index Illness(es) Illness(es)
(BMI)
Treatment/Medications for past illness (es): ___________________________________________

______________________________________________________________________________

FOR ILL MEMBERS OF THE FAMILY

NAME Illness(es)diagnosed Physical Laboratory or Treatment/Interventions

or undiagnosed Assessment diagnostic
results

D.1 Dietary history (specify quality and quantity of food intake per day)

________________________________________________________________________

________________________________________________________________________
 D.2 Eating/feeding habits/practices

________________________________________________________________________

________________________________________________________________________

D.3 Risk factor assessment indicating presence of major and contributing modifiable risk

factors for lifestyle diseases: (Please check.)

Hypertension _____ Physical inactivity _____

Sedentary lifestyle _____ Cigarette smoking _____
Elevated blood cholesterol _____ Obesity _____
Diabetes mellitus _____ Inadequate fiber intake _____
Stress _____ Alcohol drinking _____
Substance abuse _____ Others (specify) _______

______________________________________________________________________________

______________________________________________________________________________

E. VALUES, HABITS, PRACTICES ON HEALTH PROMOTION, MAINTENANCE

AND DISEASE PREVENTION

Name Immunization Rest and Exercise/ Use of Stress Use of
Status Sleep Activities Protective Management Promotive
(specify) Measures Activities preventive
(specify) Health
Services
-

______________________________________________________________________________

______________________________________________________________________________

Healthy lifestyle practices (specify):

______________________________________________________________________________

______________________________________________________________________________