CHN Week 1 Day 2 and 3 Activity Initial Data Base

Cebu Institute of Technology
University
N. Bacalso Ave., Cebu City Philippines
COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES
CHN WEEK 1 DAY 2 ACTIVITY
INITIAL DATA BASE
IN PARTIAL FULFILLMENT OF THE COURSE RLE 201
SUBMITTED BY:
Rogail R. Genturalez
BSN 2- SECTION 2 -GROUP 1
SUBMITTED TO:
MARIA ELENA CABIGON, RN., MAN., Ed.D.
CLINICAL INSTRUCTOR
Cebu Institute of Technology
University
N. Bacalso Ave., Cebu City Philippines
COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES
INITIAL DATA BASE ASSESSMENT FORM
Head of the family: Andrew Frank J. Bernaldez Sr.

Date : Nov. 16, 2021________________________________
Address (Include Important Landmark): San Roque, beside CNE building,
Zamboanga City
I. FAMILY PROFILE
A. Members of the Household
Family Age/Sex Civil Occupation Relation to Religion Highest

Members Status Family Education
Head
Andrew 40/M Married Businessman Husband Roman 1st year
Frank J. Catholic college
Bernaldez (Criminology)
Sr.
Melissa 52/F Married Assistant Wife Roman 3rd year
Jane R. Manager Catholic college
Bernaldez (Business
management)
Andrew 19/M Single Student Son Roman 2nd year
Frank R. Catholic college
Bernaldez
Sr.
Aiscel Faith 16/F Single Student Daughter Roman Junior High
R. Catholic School (Level
Bernaldez 10)
B. Total Monthly Income: Php 20, 000 Breadwinner: Andrew Frank R. Bernaldez Jr.
From: Total (Check Bracket)

Business ✓ below Php 5000 ✓____________
Landholdings __________ above Php 5000 ______________
Pension ✓ above Php 10,000 – Php 15,000 _______
Others (specify) _______________ above Php 15,000 – Php 20,000 _______
above Php 20,000 – Php 30,000 _______
above Php 30,000 – Php 40,000 _______
above Php 40,000 – Php 50,000 _______
more than Php 50,000 _______________
C. Type of Family Form:
Nuclear ✓
Matriarchal ________
Patriarchal ________
Extended ________
Homosexual Partnership ________
Cohabiting ________
Others (specify) _______________________
II. HEALTH STATUS
A. Maternal Reproductive History: (For each pregnancy, please answer the following questions
using the chart found below.)
Child Outcome Sex Weeks Mother’s Year Pre-natal Care Attendant

Age Done at Birth
Family
Planning
Practice
No. of Times
By Whom
Andrew NSVD M 28 33 years ✓ 2 Medical Social 3 condom

media
Frank R. weeks old 2002 Midwife
Bernaldez
Jr.
Aiscel NSVD F 42 36 years 2004 ✓ 3 Medical Social 2 condom
media
Faith R. weeks old Midwife
Bernaldez
1. What was the outcome? (NSVD, Caesarean Section, Others)

2. Sex of the baby
3. Weeks of gestation before the termination of pregnancy
4. Maternal age at the termination of pregnancy
5. Year pregnancy occurred
6. Prenatal Care (PNC) done: the number of times it was done: who perform the PNC (medical:
MD., RN, Midwife or non-medical)
7. Attendant at delivery (medical OR non-medical)
8. Family Planning Practice before each pregnancy (source of information & supply, method
used, number of months such method was used)
III. PHYSICAL ENVIRONMENT
A. HOME
1. Ownership
House: ✓ owned ________ rental _________ rent-free _______ others
Lot: ✓ owned ________ rental _________ rent-free _______ others
2. Construction materials used:

________ light
________ mixed
✓ strong
3. Home Appliance Present: Refrigerator, Television, Electric Fan
4. Cooking Facility:
Electric stove
firewood/charcoal
✓ Gas stove
5. Draining Facility:
Open drainage
✓ Close drainage
B. WATER SUPPLY
1. Water Source:
Public
✓ Private
Electric water pump
Open well (tabay)
Ripped system
Artesian well (Bomba)
Others (Specify)
2. Water Transport:
✓ With cover
Without cover
Bottles
Cans
Pails
Others (Specify)
3. Water Storage:
✓ With cover Without cover
✓ pail/jar with faucet pail/jar without faucet
cans plastic gallon
✓ pitcher others (specify)
4. Water Purification:
None
✓ Yes
Chlorinated
Boiling
Others (specify)
5. Approximate distance of the water source from the house: 2 m

B. Child Care: For each 12 years old and below, please answer the following questions using the
chart below.
Child Age Weight Immunization Source of Attendant Breastfed Living

Income When
Sick
1. Age of the Child

2. Weight at present
3. Has the child received any vaccinations? What kind? (Health Centers, Private Physicians)
4. For any sickness, where do you bring your child for consultation?
5. Did you breastfeed this child?
6. Is this child still living? If NO, what was the age of death?
Have any of the children passed out worms or had POSITIVE stool exam for worms?
______ No _______ Yes Was deworming done? _________
Is there any member of the family who is sick at present?

______ No _______ Yes What illness? ________________
Where do you usually go for medical care?

_________ Private hospital ________ Government hospital
__________Private doctor ________ Relatives
________ Barangay Health Worker ________ Self care
_________ Hilot ________ Others (specify)
Approximate distance of the house to the nearest health center? ___________m
C. Toilet
_____ open pit privy ______ antipolo system ______pail system ______ closed pit privy
_____ flush type ______ water sealed ______others (specify)
D. Garbage Disposal
_____ Open dumping ______ burning ______ buried in a pit
_____ collected by garbage truck _____ Composting ______ others (specify) ________
IV. SOCIO-CULTURAL
1. Are you a member of any civic or religious organization?
______ No ________ Yes (specify name of organization) _____________________
2. What is usual source of current information?

______ radio ________ newspaper ________neighbor _______ television
______ other family members ________others (specify) _____________________
3. What is usual means of relaxation?

______ sports ________ gambling ________ sleeping
______ TV/movies ________ others (specify)
4. If you feel you need help of any kind, who do you approach first?
______ priest ________ public official ________ teacher ________ neighbors
______ other family members ________ others (specify)
5. Please list down any taboo you may be able to extract from the respondent in terms of
health practices.

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Cebu Institute of Technology

CHN WEEK 1 DAY 2 ACTIVITY

INITIAL DATA BASE

IN PARTIAL FULFILLMENT OF THE COURSE RLE 201

INITIAL DATA BASE ASSESSMENT FORM

Head of the family: Andrew Frank J. Bernaldez Sr.

A. Members of the Household

Family Age/Sex Civil Occupation Relation to Religion Highest

From: Total (Check Bracket)

II. HEALTH STATUS

Child Outcome Sex Weeks Mother’s Year Pre-natal Care Attendant

Andrew NSVD M 28 33 years ✓ 2 Medical Social 3 condom

1. What was the outcome? (NSVD, Caesarean Section, Others)

2. Construction materials used:

3. Home Appliance Present: Refrigerator, Television, Electric Fan

5. Approximate distance of the water source from the house: 2 m

Child Age Weight Immunization Source of Attendant Breastfed Living

1. Age of the Child

Is there any member of the family who is sick at present?

Where do you usually go for medical care?

Approximate distance of the house to the nearest health center? ___________m

2. What is usual source of current information?

3. What is usual means of relaxation?

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