NAGA COLLEGE FOUNDATION

College of Health Sciences

City of Naga, Philippines

FAMILY CASE PROFILE

QUESTIONNAIRE

FAMILY NAME OF FAMILY CLIENTE: Borlado

COMPLETE ADDRESS Zone 4, San Vicente, Pili, Camarines Sur
TIME OF INTERVIEW WITH FAMILY: 12:57 p.m.
DATE/S OF INTERVIEW/S WITH FAMILY: Novemeber 20, 2023

I- INITIAL DATABASE
A. Family Background, Structure, Function, Dynamics and Characteristics
Ilan ang miyembro ng pamilya: 7
Sino ang namumuno ng pamilya: Linda at Pedro
Posisyon sa pamilya: Magulang

Family Age Sex* Civil Relationship Educational Occupation Religion

Members Status** to the Family Attainment
Head

Pedro R. 52 M M Father V Jeepney driver Roman

Borlado Catholic

Linda A. 53 F M Mother CG Permanent clerk Roman

Borlado Catholic

Charlene 25 F S Daughter CG Teacher Roman

A. Borlado Catholic

Allysa 25 F S Daughter CG Teacher Roman

Marie A. Catholic
Borlado

Hannah 23 F S Daughter CG Call center Roman

Mae A. Catholic
Borlado

Emil Jhun 21 M S Son CS Student Roman

A. Borlado Catholic

Erika Mae 19 F S Daughter CS Student Roman

A. Borlado Catholic

OTHER MEMBERS

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 *F-Female; M-Male
**S-Single; M-Married; W1-Widower; W2-Widow; S-Separated;A-Annulled

DIRECTION: Put a check (/) to indicate answer from the options presented
Family Structure: (/) Nuclear ( ) Dyad ( ) Extended ( ) Blended/Reconstituted
( ) Compound ( ) Cohabiting/Live-in ( ) Single Parent
( )Gay or lesbian family ( ) No kin ( ) Foster ( ) Others ________
Family Function:
Decisions in the Family (Authority): ( ) Patriarchal ( ) Matriarchal
(/) Egalitarian ( ) Democratic ( ) Autocratic ( ) Laissez Faire
( ) Matricentric ( ) Patricentric ( ) Others _____________

DIRECTION: Put a check (/) to ALL THAT APPLIES

Family Dynamics:
Anong klase ang Relasyon sa loob ng Pamilya
(/) Kaaya-aya (/) May interaksyon sa loob ng pamilya ( ) Hindi naguusap-usap
( ) Iba pa ______________

Ang gawain sa loob ng bahay

(/) tulong tulong ( ) Nanay lang ( ) Tatay at Nanay ( ) Panganay na anak
( ) Lolo/Lola ( ) kamag anak ( ) kasambahay ( ) iba pa ___________

Pag may suliranin sa loob ng pamilya

( /) tulong tulong sa paglutas ( ) magulang ang humaharap
( ) nagkokonsulta sa mga Nakakatanda ( ) nag rereport sa barangay
( ) humihingi ng tulong sa kamag anak ( ) lumalapit sa pulitiko/ahensya ng gobyerno
(/) nagdarasal/ipapasa Diyos ang suliranin ( ) iba pa _________

B. Socio-Economic and Cultural Characteristics

DIRECTION: Put a check (/) to indicate answer from the options presented.
Anong lenggwahe o dialect ang gamit ng pamilya sa pag uusap
( /) bikol ( ) tagalog ( ) bisaya ( ) Ilonggo ( /) ingles ( ) iba pa_____

Ano-ano ang mga tulong na natanggap na at tinatanggap ng pamilya :

( ) gobyerno ( ) NGOs ( ) civic organizations ( ) simbahan ( ) indibidwal
( /) programa ng mga institusyong pang edukasyon

Gaano ka epektibo ang mga tulong na nakamit ng pamilya ( /) epektibo ( ) walang epekto

Ano ang main na pinagkukunan ng pagbuhay ng pamilya pagtatrabaho ng ina sa gobyerno

Ibang pinagkukunang pagbuhay ng pamilya_pagmamaneho/pagpapasada ng jeep ng ama

Magkano ang combined/gross na buwanang kita ng pamilya

( ) Below PHP 1,000 ( ) PHP 1,001-3,000 ( )PHP 3,001-5,000
( ) PHP 5,000 -7,000 ( ) PHP 7,000 – 10,000 ( /) PHP 12,500 and Above

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 Mga pinagkakagastusan:
DIRECTION: Lagyan ng bilang (1) pinaka-importante, (7) pinaka-mababa, (N/A) kung hindi
pinagkakagastusan
Pagkain 1 Tubig 1 Kuryente 1 Pag-aaral 1 Transportasyon 7 Medikal 1
Netflix N/A Internet 7 Telepono 7 Libangan N/A Ipon 1 Bisyo (sabong) N/A
Sugal N/A Sigarilyo N/A Alak N/A Iba pa (specify) _________

C. Home and Environment

DIRECTION: Put a check (/) to indicate the answer from the options presented.
Klase ng Bahay:( ) konkreto ( / ) mixed materials (semi-concrete)
( ) light materials specify: ________________

Estado ng pamilya sa bahay na tinitirhan: ( ) Pag-aari ( ) Nirerentahan

( /) Nakikitira ( ) iskwater

Dibisyon ng Bahay: ( / ) sala ( /) kwarto ( / ) Lutuan/kusina ( / ) Palikuran

( ) Iba pa ______________

Sleeping Arrangements:( ) Magkakasama sa isang tulugan

( / ) Hiwalay ang mga anak sa magulang
( ) kanya kanyang kwarto ( ) iba pa _____________

Accident Hazards: _____________________________________________________________

____________________________________________________________________________

Mga posibleng pinanggalingan ng sakit: ____________________________________________

____________________________________________________________________________

Klase ng ginagamit sa pagluluto: ( ) Kahoy ( ) Uling ( / ) Gas

( ) Iba pa ______________________

Klase ng pinagtataguan ng Pagkain: ( / ) Refrigerator ( ) Plastic wares ( ) Iba pa _____

Pinanggagalingan ng tubig: ( / ) NAWASA ( ) Poso ( ) Balon

( ) Batis/Ilog ( ) Rasyon ( ) iba pa____________

Toilet Facility: ( / ) May-arI ( ) Nakikigamit ( ) Walang sariling toilet

Uri ng Toilet Facility: ( / ) Water-sealed ( ) Flush Type ( ) Pit-privy ( ) Others_____

Waste Disposal: ( / ) Compost Pit ( ) Open Burning ( ) Garbage Collection

( ) Others____________

Drainage: ( / ) Open ( ) Closed

Facilities found in the Barangay

( / ) Barangay hall ( / ) Health Center ( / ) Day Care Center( / ) Basketball Court
( ) Lying-in ( ) Women's Center ( ) Schools ( ) Wet Market
( ) Crematorium ( / ) Grocery Stores ( ) Others:________________

Communication
( / ) Cellphone ( ) Telephone ( ) Postal ( ) Email
( / ) Social Media ( ) Radio/Kabalikat ( ) Bulletin ( ) Others_________

Sources of Information: ( ) Newspapers/ Magazines ( / ) Television ( / ) Radio

( / ) Internet ( ) Others____________

Domestic Animals
TYPE OF NUMBER OF BREED LOCATION CAGE STATUS OF
ANIMAL ANIMALS VACCINATION If
applicable
Dog 3 

Aspin
Half ]Loob ng No
No
Vaccinated -
Rabbies
3
 aspin bahay Vaccinated-
Rabbies
 Labrador Nasa labas Vaccinated-
ng bahay Yes Rabbies

D. Health Assessment of Each Family Member

D1. Past and Present Illnesses

MEMBERS PAST PRES CHECK ADMITTE HAD AN TREATED TREATE GIVEN REM
ILLNE ENT UP AT D TO OPERATI BY D BY MEDICA ARK
SSES ILLNE CLINIC/ HOSPITAL ON ALBULAR HILOT TIONS S
SSES CENTER YO
Pedro R.
Borlado
Jr.
Linda A. Pyrexia Comm
Borlado on YES NO NO NO NO YES
Colds
Charlene
A. Borlado
Allysa A.
Borlado
Hannah A.
Borlado
Emil Jhun
A. Borlado
Erika Mae
A. Borlado

OTHER MEMBERS

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LEGEND: Hypertension, Common colds, Diabetes, Covid-19, Tuberculosis, Asthma, Cancer, Kidney disease, Scabies, Pediculosis, Psychosis,
Neurosis, Bipolar Disorder, Generalized Anxiety

D2. Family Health Assessment based on Functional Health Pattern

DIRECTION: Put a check (/) to indicate answer from options presented.

FUNCTIONAL
HEALTH DESCRIPTION MGA TANONG SAGOT REMARKS
PATTERN
Health Describes client’s ● Kumusta ang buhay ( / ) mabuti
Perception- perceived pattern kalusugan ng ( ) di mabuti
health of health and well pamilya ?
management being and how
patterns health is
● Nagkaroon ba ng
managed. ( / ) meron
pagkakasakit sa
( ) wala
pamilya sa nakalipas
na taon ?
● Nagresulta ba ito sa
di pagpasok /di ( / ) oo
pagtatrabaho at pag ( ) hindi
pasok sa school?

● Naniniwala po ba
kayo sa turo ng mga ( / ) oo
doctor, nurses at ( ) hindi
midwives sa center at
hosp?

● Naniniwala po ba
kayo sa pagbabakuna ( / ) oo
ng mga bata at ( ) hindi
matanda?

● Aling mga health ( / ) hospital

resources ang iyong ( / ) clinic
ina avail? Check all ( / ) barangay health
that apply center
( ) hilot
( ) albularyo
( / ) herbal
medicine
( ) iba pa

● Distansya ng bahay sa
Health Facility Tatlong street mula sa
bahay
Nutritional- Describes ● Ano ang tipikal na ( / ) gulay
metabolic pattern of food pagkain ng pamilya ? ( / ) kanin
pattern and fluid ( / ) isda
consumption ( / ) fruits
relative to ( / ) karne
metabolic need ( ) de lata
and pattern ( ) noodles
indicators of ( ) iba pa____
local nutrient
supply. 1-3x/
● Gaano kadalas
a week gulay
kumain pagkain ng
Thrice a day
pamilya ?
a week kanin
Once a day
1-3x/ week
Twice a day
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 Thrice a day a week isda
1-3x/ week 1-3x/ week
4-6x/ week a week fruits
1-3x/ week
a week karne

1-3x/ week
processed foods
____ noodles
1-3x/ week
fast food
___________ iba pa

● Nagtatake po ba kayo
( / ) oo
ng
( ) hindi
supplements/vitamins
?

● Tipikal na pag inom ( / ) less than

ng tubig bawat araw 8 glasses
( ) more
than 8
glasses

● Magana bang kumain

( / ) magana
ang pamilya?
( ) walang
Gana
● May food or eating
discomfort? Paglolon? ( ) meron
Diet restrictions? If ( / ) wala
appropriate,
breastfeeding? May
problem ba sa pag
breastfeeding?

● May skin problems, ( ) meron

lesions, dryness? ( / ) wala

● May dental problems? ( ) meron

( / ) wala

Elimination Describes ● May problem ba sa ( ) meron

pattern pattern of bowel elimination? ( / ) wala
excretory Sa pag ihi ?
function (bowel,
bladder, and ( ) meron
● Malakas ba ang pag
skin ( / ) wala
perspire? May odor
problems ba?

Activity- Describe ● May sapat ang lakas ( / ) meron

exercise patterns of sa araw na gawain? ( ) wala
pattern exercise,
activity, leisure, ( / ) walking
● Uri ng ehersisyo
and recreation. ( / ) dancing
( ) biking
( ) jogging
( ) weight

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 lifting
( ) iba pa _________
( ) wala

● Ano ang pattern ng ( / ) regular

pag eehersisyo ? 1x/wk
( ) Daily
monthly
( ) hindi nag
Eehersisyo

( / ) tv
● Ano ang libangan ng
( / ) radio
adult members ng
( / ) Kdrama
pamilya?
( / ) online games
( ) baraha
( ) chismis

( ) online games
● Ano ang mga ( ) tv
laro/libangan ng mga ( ) tumbang preso
bata ? ( ) Chinese garter
( ) iba pa_________

● Ano ang malimit na

activities ng
Tatay - Pag eehersisyo
Nanay
Mga anak - Pag-uusap
Ibang members usap/bonding

Sleep-rest Describes ● Generally rested at ( ) oo

pattern patterns of ready sa activities ( / ) hindi
sleep, rest, after sleep?
and
relaxation. ( / ) meron
● Merong may insomnia
( ) wala
sa pamilya?
( ) meron
● May binabangungot ba ( / ) wala
sa pamilya?

Cognitive- Describes ● Meron bang may ( ) meron

perceptual sensory, hearing difficulty sa ( / ) wala
pattern perceptual, and pamilya?
cognitive
pattern
● Meron bang may
( / ) meron
problema sa mata?
( ) wala
Gumagamit na ba ng
eyeglasses?

● May pagbabago ba sa
memorya ng ( ) meron
kapamilya? ( / ) wala

● Meron bang may ( / ) meron

discomfort? Pain sa ( ) wala
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 pamilya?

Self- Describes self- ● Malimit ba na mabuti ( ) oo

perception/self concept and ang tingin mo sa sarili ( / ) hindi
-concept perceptions of mo ?
self (body
comfort, image, ( ) oo
● Pag may changes sa
feeling state) ( / ) hindi
iyong katawan eto ba
ay nagiging problema
para saiyo?

● Sino madalas na ( / ) Asawa

nakaka pag galit sayo? ( / ) anak
Nakakapag paalala? ( ) parents
Nakakainis? ( ) neighbor
Nakakapagpa ( ) kasama
Lungkot? Naka sa trabaho
kacause ng takot? ( ) kaibigan
( ) iba pa_________

● Ever feel you lose - Yes, travel

hope? Not able to
control things in life?
What helps?

Roles and Describes ● Pano hina handle ng ( / ) pinag

relationship pattern of role pamilya ang mga uusapan
engagements pagsubok? ( ) hingi ng
and Tulong
relationships. ( / ) ipagdasal
( ) iba pa_________
( ) hayaan
lang

● If appropriate, may
( ) meron
problem ba sa mga
( / ) wala
anak ? mahirap
ihandle?

● Kabilang ba ang ( / ) kabilang

pamilya sa mga social ( ) hindi kabilang
groups?

● May malapit bang mga ( / ) meron

friends? ( ) wala

● Pakiramdam na
( / ) kabilang
kabilang sa komunidad
( ) hindi kabilang
na tinitirhan

Sexual / Describes ● If appropriate to ( ) meron

Reproductive client’s pattern age/situation, ang ( ) wala
of satisfaction sexual na relasyon po
and ba ninyo ay wala
dissatisfaction namang problema?
8
 with sexuality
pattern, ● If appropriate, ( ) Natural Family
describes gumagamit po ba kayo Planning
reproductive ng contraceptives? Or ( ) Artificial Family
patterns. nagfa-family planning? Planning

● For females, kelan

nagsimula ang
menstruation? Kelan
ang huling menstrual
period? May menstrual
problems ba? Para?
Gravida?

Coping- stress Describes ● Meron bang big ( / ) meron

tolerance general coping changes na naganap ( ) wala
Pattern patterns and sa buhay nyo last year
effectiveness of or two? Crisis?
the pattern in
terms of stress ( / ) pamilya
● Sino ang
tolerance. ( / ) kaibigan
makakatulong sa inyo
( ) gobyerno
pagka dumadaan kayo
( ) NGOs
sa pag subok?
( ) civic grp
( / ) simbahan
( ) wala

● Pag tensed kayo ( ) gumagamit

gumagamit ba kayo ng ( / ) hindi gumagamit
gamot? Drugs?
Alcohol?

Values/ Belief Describes a ● Mahalaga ba ang ( / ) mahalaga

Pattern pattern of paniniwala sa relihiyon ( ) hindi
values and sa pamilya? mahalaga
beliefs, including
spiritual and /or ( / ) oo
● Nakakatulong ba ang
goals that guide ( ) hindi
inyong paniniwala sa
choices or
Diyos sa pagharap sa
decisions.
mga pagsubok?
( / ) meron
● May importanteng ( ) wala
plano ba ang pamilya
sa hinaharap? If so,
ano yun?

MEMBERSHIP IN ORGANIZATIONS:
DIRECTION: Put a check (/) in the appropriate column to indicate answer/s
4Ps SENIOR PWD SOLO GSIS SSS 4H CHURCH OTHERS NONE
MEMBERS CITIZEN PARENT (Specify) (Specify)

Pedro R. /
Borlado Jr.
Linda A. /
Borlado
9
Charlene /
A. Borlado
Allysa /
Marie A.
Borlado
Hannah /
Mae A.
Borlado
Emil Jhun /
A. Borlado
Erika Mae Church /
A. Borlado of God-
Pili

OTHER MEMBERS

MEMBERSHIP IN HEALTH CARE INSURANCE COMPANIES/ HEALTH MAINTENANCE

ORGANIZATIONS (HMOs): DIRECTION: Put a check (/) in the appropriate column to
indicate answer

HEALTH CARE INSURANCE COMPANIES/ NAME OF FAMILY MEMBER NON-MEMBER

HEALTH MAINTENANCE ORGANIZATIONS MEMBERS
(HMOs)

Philhealth Linda A. Borlado /

Charlene A. Borlado /
Allysa Marie A. /
Borlado
Hannah Mae A. /
Borlado
Carehealth Plus Systems International, Inc.
Asalus Corporation (Intellicare)
Carewell Health Systems, Inc.
Caritas Health Shield, Inc.
Fortune Medicare, lnc.
Health Maintenance, lnc
Health Plan Philippines, Inc
10
Insular Health Care, Inc.
AXA
Philam
Others(Specify):
‘
IMMUNIZATION STATUS OF FAMILY
DIRECTION: Put a check (/) in the appropriate column to indicate answer

Family Immunization Status COVID-19 Vaccine

Members Remarks

Complete Incomplete 1st 2nd 1st 2nd

dose dose booster booster

Pedro / / /

Linda / / /

Charlene / / /

Allysa / / /
Marie

Hannah / / /
Mae

Emil jhun / / /

Erika Mae / / /

OTHER MEMBERS

Legend: Complete = immunized with BCG, HEPA B, PentaVac, OPV, IPV, PCV, ROTA, MMR

OTHER VACCINES: _____________________________________________________

DIRECTION: Put a check (/) to ALL THAT APPLY from options presented.
Transportation
( ) Tren ( ) Motor ( ) Padyak ( ) Bangka ( / )Jeep ( ) Skates
( ) Tricycle ( ) Bisikleta ( ) kalabaw ( / ) iba pa Van

11
 Breastfeeding
Sa mga anak kung nabreasfeed: ( / ) oo, Gaano katagal? __________
( ) Hindi, Bakit at ano ang pinasuso?_________

Maternal Record
Ilang buwan ng buntis, pang ilang anak na? _________________________________________
Kailan ang huling regla? _________________________________________________________
Ano-anong gamot ang iniinom? ___________________________________________________
Ano ang trabaho? ______________________________________________________________
Ano ang bisyo, kung meron? _____________________________________________________
Nageehersisyo? ano at paano? ___________________________________________________
Nagpapacheck-up ba? Saan at gaano kadalas? _______________________________________

III. FAMILY COPING INDEX

Scaling: 1- No Competence 3- Moderately Competence 5- Complete Competence

CRITERIA IDEAL ACTUAL RATING JUSTIFICATION
1. Physical Is involved with the
Independence ability to move around, to 5
get out of bed, to take
care of daily hygiene,
walking, etc
2. Therapeutic Involves all procedures or
Competence medications prescribed 3
for the treatment of
illness, such as
prescription drugs,
appliances, dressing,
exercise, stress relief,
diet plans, etc
3. Knowledge Associated with the
of Health specific health condition 3
Condition that gives rise to
treatment, such as the
awareness of the disease
or the inability to
comprehend the
communicability of
illnesses and the mode of
transmission. Recognizing
the general pattern of
development of newborn
infants and basic physical
care needs of infants
4. Application Concerned with family
of Principles action in relation to 3
of General preserving family
Hygiene nutrition, ensuring
adequate rest and
relaxation for family
members, implementing
accepted precautionary
measures (immunization,
medical assessment, safe
home-making in relation
to food storage and
preparation).
5. Health Primarily concerned with
Attitudes the way the family feels 3
about health care in

12
 general, including
preventive services,
health care and public
health measures
6. Emotional It has to do with the
Competence maturity and integrity 5
with which the members
of the family are able to
cope with the usual stress
and problems of life, and
to plan for a happy and
fruitful life. The extent to
which individuals
recognize the appropriate
disciplines enforced by
their own family and
culture. Developing the
responsibilities and
decisions of the
individual. An eagerness
to meet sensible
responsibilities, to accept
fortitude adversity, to
consider the needs of
others as well as one's
own.
7. Family Concerned about the
Living interpersonal or group 5
aspect of family life.
Members of the family
get along with each
other, the ways in which
they make decisions that
affect the family, the
extent to which they
support each other and
do things as a family, the
degree of respect and
affection, and the way in
which they organize the
household finances
8. Physical Concerned with the
Environment home, community and 5
work environment as it
affects family health.
House conditions such as
accident hazard
pressure, screening,
plumbing, system,
cooking facilities,
privacy, community level
(deteriorated
neighborhood, presence
of social hazards, pests),
school transport and
accessibility.
9. Use of Degree of use of the
Community family and awareness of 3
Facilities the community facilities
available for welfare and
education.

IV-TYPOLOGY OF NURSING PROBLEM

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 Discusses the problems that were identified during assessment and interview with the family.
It includes the cues/data, the family nursing problem and the nursing diagnosis. The problems
identified are categorized into the presence of wellness state, health deficits, health threats,
foreseeable crisis and stress points.

Typology of Nursing Problems identified in Family

CUES OR DATA FAMILY NURSING PROBLEMS

V-PRIORITIZING PROBLEMS
Shows the setting of priorities of family health problems that have been identified. It
includes a computation on how priorities were shown with their corresponding justification
FAMILY HEALTH PROBLEM #1:
CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION
1.Nature of the
Problem

2. Modifiability of
the Problem

3. Preventive
Potential

4. Salience of the
Problem

TOTAL SCORE

FAMILY HEALTH PROBLEM #2:

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION
1.Nature of the
Problem

14
2. Modifiability of
the Problem

3. Preventive
Potential

4. Salience of the
Problem

TOTAL SCORE

FAMILY HEALTH PROBLEM #3:

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION
1.Nature of the
Problem

2. Modifiability of
the Problem

3. Preventive
Potential

4. Salience of the
Problem

TOTAL SCORE

FAMILY HEALTH PROBLEM # 4:

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION
1.Nature of the
Problem

2. Modifiability of
the Problem

15
 3. Preventive
Potential

4. Salience of the
Problem

TOTAL SCORE

FAMILY HEALTH PROBLEM #5:

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION
1.Nature of the
Problem

2. Modifiability of
the Problem

3. Preventive
Potential

4. Salience of the
Problem

TOTAL SCORE

VI- FAMILY NURSING CARE PLAN

Shows the identified and prioritized problems in a ranking order. This chapter also
presents the family care plan formulated by the student nurse together with the family.
PROBLEM LIST
PROBLEMS SCORE

16
 _____Erika Mae A. Borlado/ 2-F________
INTERVIEWER
(Signature over printed Name of Student/ Group-Year and Section)

17