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

Status Attainment the Family with
(Age) Family or
Not
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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 care:

_____________________________________________________________

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

conflict between members; characteristic 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 = ________________________________

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B.1 Breakdown of Expenses (Monthly)

____________________________________________ = P ________________

____________________________________________ = ________________

____________________________________________ = ________________

____________________________________________ = ________________

____________________________________________ = ________________

Total Monthly Expenses of the Family = ________________

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

____________________________________________________________________

B.3 Who makes decisions 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 Type 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. mosquitoes,

flies, etc.): __________________________________________________________

C.6 Presence of accident hazards: ___________________________________________

C.7 Food storage and cooking facilities:

Food storage (Please check.)
Refrigerated ____________ Not refrigerated ________________

Covered ________________
Uncovered _______________
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Cooking Facility (Please check.)

Electric stove ________ Gas stove ______ Firewood/Charcoal ________

C.8 Water supply (source, ownership, potability): (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 plant _______

__________________________________________________________________

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.12 Community and transportation facilities available __________________________

___________________________________________________________________

D. HEALTH STATUS OF EACH FAMILY MEMBER

Name Height Weight Body Vital Past Present

Mass Signs Illness(es) Illness(es)
Index
(BMI)
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Treatment/Medications for past illness(es): ____________________________________

_______________________________________________________________________

FOR ILL MEMBERS OF THE FAMILY

Name Illness(es) – Physical Laboratory or Treatment/

diagnosed or Assessment diagnostic Interventions
undiagnosed 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 specific 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) ________

________________________________________________________________________

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

AND DISEASE PREVENTION

Name Immuniz Rest Exercise/ Use of Stress Use of

ation and Activities Protective Management Promotive-
Status Sleep Measures Activities preventive
(specify) (specify) Health
Services

________________________________________________________________________

________________________________________________________________________

Healthy lifestyle practices (specify):

________________________________________________________________________

_______________________________________________________________________

References:

Maglaya, Araceli (2004). Nursing Practice in the Community. 4th ed. Marikina
City:Argonauta Corporation

Gesmundo, Monina (2010). The Basics of Community Health Nursing: A Study Guide
for Nursing Students and Local Board Examinees. Quezon City: C & E
Publishing, Inc.

FM-CHS- 00 04-25-2023
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