INITIAL-DATA-BASE-form-for-family-TEMPLATE 2

COMMUNITY HEALTH NURSING RLE
PART A. INITIAL DATA BASE

I. FAMILT CHARACTERISTICS:
A. What is the type of family structure?
Nuclear Single - Parent
Extended Others (specify)
B. What is the type of family based on authority?
Patriarchal
Matriarchal
C. Who makes decisions regarding health care?
D. What is the present family relationship?
with conflicts between members
without conflicts between family members
E. Activities of daily living:
1. Sleeping pattern:
Retiring/getting up hours
Nap during the day
Do members sleep together
2. Eating pattern
How many meals each day?
Who appears overweight?
Who appears underweight?
3. Leisure time activities
How does each member spend leisure hours?
Is it appropriate for the sex and age group?
What is the effect on the family?
Any joint activity for leisure?
II. FAMILY INFORMATION

Head of the family:
Address:
Members of the household:
NAME RELATION TO THE AGE EDUCATIONAL ATTAINMENT

HEAD
/avg 1
III. SOCIO-ECONOMIC AND CULTURAL FACTORS
A. Income
NAME OCCUPATION PLACE INCOME /

MONTH
1. Does the working family member meet the basic necessities?

Yes No
2. Who makes decisions regarding money matters?
3. Religious affiliation:
4. What roles does the family play in the community?
IV. ENVIRONMENTAL FACTORS

A. Housing
1. Ownership
Owned Rented Rent-Free Others (specify)
2. Construction materials used
Light Mixed Strong
3. Living space
Adequate Inadequate
4. Sleeping arrangement:
5. Adequacy in furniture
Adequate Inadequate
6. Water source
Private Public Potability?__________________
7. Food storage
Refrigerator Jars/container Others (specify)
8. Cooking facility
Electric stove Firewood _____ Charcoal
Gas Stove Kerosene ___________ Others (specify)
9. Drainage facility
Open drainage Blind drainage None
10. Toilet facilities/type
Flush type Overhung latrine Bored-hole latrine
Water-sealed latrine Open-pit privy _______ Closed-pit privy
Pail system None _______ Others (specify)
11. Garbage disposal
Open Dumping Picked up by garbage collector
Burial in pit Open burning
__________ Hog feeding ____________ Composting Others(specify)
12. Domestic Animals
Type Number Where Kept
/avg 2
13. The Community in General
a.Sanitary condition
Fair Good Poor
Provide brief description:
b.Neighborhood (housing congestion)

Yes No
c. Presence of Breeding Sites of Vectors of Diseases:
_________Yes; Specify __________________________ _________ None
d. Recreational facilities: ____________________________________________
e. Availability of Health Care Services and its facility ( Describe briefly) _______
_________________________________________________________________
f.Distance of house to the nearest health care facility _____________________
_________________________________________________________________
Describe briefly:
V. HEALTH MEDICAL HISTORY

NAME PAST ILLNESS DIAGNOSED / ILLNESS STATE HEALTH ACTION
UNDIAGNOSED TAKEN
VI. VALUE PLACED ON PREVENTION OF
DISEASE Vaccinations
NAME- AGE COMPLETE INCOMPLETE

vaccines
Other preventive practices employed by the family:
Sources of Health Care:

Health Center Government Hospital
Private Hospital Others (specify)
Surveyed by _________________________ Date ______________________________

/avg 3
PART B.
Identify At Least 3 Health Problems Of The Family, Or If None, Identify The Family'S Promotive Or Preventive Practices.
FAMILY HEALTH PROBLEMS. / TYPOLOGY OF HEALTH PROBLEM

(WELLNESS STATE , HEALTH DEFICIT,HEALTH THREAT,
(IF NONE, FAMILY’S PROMOTIVE OR FORESEEABLE CRISIS)
PREVENTIVE PRACTICES.)
PART C.
Prioritizing / Scaling Of The 3 Identified Health Problems Or Promotive Practices Of The Family.
HEALTH PROBLEM :
CRITERIA COMPUTATION ACTUAL JUSTIFICATION

SCORE
NATURE OF THE
PROBLEM
MODIFIABILITY
OF THE
PROBLEM
PREVENTIVE
POTENTIAL
SALIENCE
TOTAL
HEALTH PROBLEM 2:
CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION
NATURE OF THE PROBLEM
MODIFIABILITY OF THE
PROBLEM
PREVENTIVE POTENTIAL
SALIENCE
TOTAL
Part D.
/avg 4
Family Nursing Care Plan (FNCP)
/avg 5

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COMMUNITY HEALTH NURSING RLE

PART A. INITIAL DATA BASE

II. FAMILY INFORMATION

NAME RELATION TO THE AGE EDUCATIONAL ATTAINMENT

NAME OCCUPATION PLACE INCOME /

1. Does the working family member meet the basic necessities?

IV. ENVIRONMENTAL FACTORS

b.Neighborhood (housing congestion)

V. HEALTH MEDICAL HISTORY

VI. VALUE PLACED ON PREVENTION OF

NAME- AGE COMPLETE INCOMPLETE

Other preventive practices employed by the family:

Sources of Health Care:

Surveyed by _ Date ______

FAMILY HEALTH PROBLEMS. / TYPOLOGY OF HEALTH PROBLEM

CRITERIA COMPUTATION ACTUAL JUSTIFICATION

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

NATURE OF THE PROBLEM

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