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
2. Extended family
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
conflicts between
family members
Without conflict
TOTAL = 100%
2. Characteristics of Negative
communication characteristic
Positive
characteristic
TOTAL = 100%
3. Interaction Negative
patterns among interaction
members
Positive interaction

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

MOSTLY
HEALTHY
HEALTHY

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
1
2
3
4
5

GROUP 2
RANK FELT NEED NO. OF RESPONSES
1
2
3
4
5
GROUP 3
 RANK FELT NEED NO. OF RESPONSES
1
2
3
4
5
GROUP 4
RANK FELT NEED NO. OF RESPONSES
1
2
3
4
5

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 INADEQUATE
SPACE 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
INCOMPLETE (on-going)
COMPLETE
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
INCOMPLETE (on-going)
COMPLETE
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
2
3
4
b. Exercise 1
2
3
4
c. Relaxation activities 1
2
3
4
d. Stress management activities 1
2
3
4
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
neighborhood 2
3
4
5
OVERALL TOTAL = 100%
Social and health 1
facilities available 2
3
4
5
OVERALL TOTAL = 100%
Communication 1
and transportation 2
facilities
3
4
5
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