UNIVERSITY OF CEBU – BANILAD

COLLEGE OF NURSING

INITIAL DATA BASE FOR FAMILY NURSING PRACTICE

Family Surname :
Barangay : Municipality/ City: ________
Source (s) of Information: - Contact No: ____ Date:

Data Gathering: __________ Type of Family:

A. HOUSEHOLD MEMBERS (all who resides in the family home)

RELATIONSHIP HIGHEST NUTRITIONAL

CURRENT
NAME GENDER AGE TO HEAD OF EDUCATIONAL OCCUPATION ASSESSMENT
HOUSEHOLD HEALTH PROBLEMS
ATTAINMENT (Healthy/At Risk)

Note: Insert genogram, family tree (indicating health problems of individual members)

11 | P a g e
 GENOGRAM OF FAMILY
(NAME)

Grandparent Grandparent Grandparent

Grandparent

Aunts and Uncles

Parent Parent

Child Child

2|Page PMV- lanie / joy (edited) 06/27/2016

 FAMILY HEALTH TREE OF FAMILY
(NAME)

1. Causes of death of deceased family members

2. Genetically linked diseases:

( ) Heart Disease
( ) Cancer
( ) Diabetes
( ) Hypertension
( ) Allergies
( ) Asthma
( ) Mental retardation
3. Environmental and occupational diseases

4. Psychological problem (mental illness/ obesity)

5. Infectious diseases
( ) TB
( ) Hepatitis
( ) Chicken Pox
( ) Measles
( ) Others:

6. Family’s methods of illness Prevention

( ) Exercise
( ) Periodic physical examination
( ) Pap smear
( ) Immunizations

7. How family cope with stress

______________________
______________________
______________________

3|Page PMV- lanie / joy (edited) 06/27/2016

B. FAMILY CHARACTERISTICS

1. Family members living outside the household

Relationship Frequency and

Means of
Name Age to the Location operating
Communication
Household contact

2. Family Mobile
2.1 Length of the current address
2.2 Address of Previous Residence
2.3 Frequency of geographic moves

3. Family dynamics
3.1 Emotional bonding of family members
3.2 Distribution of authority and power
3.3 How members communicate
3.4 How problems are solved
3.5 How conflict is handled
3.6 Division of labor
3.7 Decision making ________________________________

C. SOCIOECONOMIC AND CULTURAL CHARACTERISTICS

1. Family Social Integration

1.1 Language(s) or dialect(s) spoken
1.2 Literacy (ability to read or write in language)
1.3 Network with religious organization
1.4 Network with social organization

4|Page PMV- lanie / joy (edited) 06/27/2016

D. CULTURAL INFLUENCES: Values, Attitudes & Beliefs about:
1. Spirituality
2. Rituals (holidays & celebrations)
3. Dietary habits
4. Health
5. Traditional healers

E. FAMILY ENVIRONMENT

1. Home
1.1. Ownership ( ) owned ( ) rented ( ) rent-free
1.2. Construction materials used ( ) light ( ) mixed ( ) strong
1.3. Adequacy of Size (# of bedrooms)
1.4. Lighting Facilities ( ) electricity ( ) kerosene
( ) others (specify)
1.5. General Sanitary Condition

2. Water Supply
2.1. Drinking water
2.1.1. Ownership ( ) individual (private) ( ) municipal (city owned)

2.1.2. Source ( ) Level 1 (point source)

( ) Level II (communal faucet system or standposts)
( ) Level III (waterworks system or individual
house connections)
( ) open dug wells
( ) unimproved springs
( ) wells not need priming
( ) rain water

2.1.3. Storage ( ) None (direct from faucet or pipe)

( ) jar or can with faucet
( ) jar or can without faucet
( ) others (specify) _

2.2. Water for household use

2.2.1. Ownership ( ) individual / private water system
( ) municipal / city water system

5|Page PMV- lanie / joy (edited) 06/27/2016

 2.2.2. Source ( ) ground water (specify) _
( ) surface water (specify)
( ) rain water

2.2.3. Storage ( ) home (direct from faucet or pipe)

( ) jar or can
( ) others (specify) _

3. Kitchen
3.1. Cooking Facility ( ) electric stove ( ) gas stove
( ) firewood / charcoal
3.2. Sanitary Condition
3.3. Drainage Facility ( ) none ( ) open drainage
( ) blind drainage

4. Water Disposal
4.1. Refuse and Garbage
4.1.1. Container ( ) covered ( ) open
( ) none

4.1.2. Methods of Disposal ( ) hog feeding ( ) open dumping

( ) open burning ( ) burial in pit
( ) burial in pit ( ) composting
( ) incineration ( ) collection by government
( ) collection from private
( ) others (specify) _

4.2. Toilet ( ) none ( ) pail system

( ) open pit private ( ) closed pit private
( ) bored hole latrine ( ) overhung latrine
( ) antipolo system ( ) water sealed latrine
( ) flush type
( ) others (specify) _

4.2.1. Distance from the house

4.3. Sanitary Condition

6|Page PMV- lanie / joy (edited) 06/27/2016

 5. Domestic Animals

KIND NUMBER WHERE KEPT

F. FAMILY NEIGHBORHOOD
1. Location
(urban, rural, subdivision, slum area)
2. Type
(residential, semi commercial, commercial)
3. Safety
3.1. Traffic pattern
3.2. Lighting
3.3. Security
4. Population density
(crowding)
5. Sources of pollution
5.1. Air
5.2. Water
5.3. Soil
5.4. Noise
6. Transportation available _______________________
7. Social facilities _______________________

G. FAMILY HEALTH & HEALTH BEHAVIOR

1. Healthy lifestyle practices (Activities of Daily Living)
____________________
____________________
____________________

2. Hours of sleep/rest per day ______________________________

7|Page PMV- lanie / joy (edited) 06/27/2016

 3. Health Problems
3.1 Health Deficit / Need: (condition that can be alleviated with medical or social technology)

3.2 Health Threats (conditions that will promote or cause disease(s) or injury(ies))

3.3 Foreseeable crisis (stressful conditions)

4. Home Remedies

5. Health Care Resources

6. Eating/ feeding habits/ practices

____________________________
____________________________
____________________________

7. Protective measures used

____________________________
____________________________
____________________________

8. Vaccination (vaccinations received)

____________________________
____________________________
____________________________

8|Page PMV- lanie / joy (edited) 06/27/2016

9|Page PMV- lanie / joy (edited) 06/27/2016