INITIAL DATA BASE
Head of the family: Family Number:
Address:
FAMILY STRUCTURE AND CHARACTERISTICS
Name Relation to head Sex Age Marital Educational Occupation Place Health
Status Attainment Type of work Remarks
INITIAL DATE BASE FOR FAMILY NURSING PRACTICE
A. Family Structure and Characteristics
1) Members of the household and relationship to the head of the family
2) Demographic Data
3) Place of Residence of each member
4) Type of Family Structure
5) Dominant Family Members in matter of health care
6) General Family Relationship
B. Social-Economic and Cultural Factors
1) Income Expenses
a) Occupation place of work and income of each working member
b) Adequacy to meet basic necessities (food, clothing, and shelter)
c) Who makes decisions about the money and how is it spent?
2) Educational Attainment of each member
3) Ethnic background and religious affiliation
4) Significant Others
5) Relationship of the Family to Larger Community
C. Environmental Factors (refer to Home and Environment)
HOME AND ENVIRONMENT Date Assessed:
1. Home
a. Ownership: ( ) Owned ( ) Rental ( ) real –Free
b. Construction Materials used: ( ) Light ( ) Mixed
c. Number of rooms used in sleeping:
d. Lighting Facilities: ( ) Electricity ( ) Kerosene ( ) Others Specify:
e. General Sanitary Condition:
2. Water Supply
a. Drinking Water
Source: ( ) Private ( ) Public
Distance from the house :
Storage: ( ) none (direct from faucet or pipe)
( ) Jar or can with faucet
( ) Jar or can without faucet
( ) Others (specify)
3. Kitchen
a. Cooking Facilities: ( ) electric stove ( ) gas stove ( ) Firewood
b. Sanitary Condition:
c. Drainage Facility: ( ) none ( ) Open Drainage
4. Water Disposal
a. Refuse Garbage
(1) Container: ( ) covered ( ) open ( ) none
(2) Method of Disposal:
( ) Hog Feeding ( ) Composing
( ) Open Dumping ( ) Incineration
( ) Open Burning ( ) Others Specify:
( ) Basial in Pit
b. Toilet
(1) Type
( ) None ( ) Antipolo System
( ) Pail System ( ) Water – sealed Latrine
( ) Open pit privy ( ) Flush Type
( ) Closed pit privy ( ) Others Specify:
( ) Bored – hole latrine
( ) Overhung latrine
(2) Distance from the house:
(3) Sanitary Condition:
5. Domestic Animals
Kind Number Where Kept
6. The Community in General
a. General Sanitary Condition:
b: Housing Congestion: ( ) Yes ( ) No
c. Recreational Facilities:
d. Availability of Health Care Facilities (Describe briefly)
e. Distance of the house from the nearest health care facilities:
D. Health Assessment of each Member
1) Medical and Nursing History indicating illness, conducive to illness.
2) Nutritional Assessment (for vulnerable or at-risk members)
a. Anthropometric data
Mid-Upper arm circumference
Height
Weight
b. Dietary History indicating quality and quantity of food intake
c. Eating/Feeding habit/Practices
3) Current Health Status Indicating Presence of Illness States
E. Valued Placed on Prevention of Disease
1) Immunization State of Children
2) Use of other preventive services
Name:
Clinical Experience:
Clinical Area:
Date:
Time:
Clinical Instructor:
FIRST LEVEL ASSESSMENT
A. HEALTH TREATS
B. HEALTH DEFICITS
C. FORESEEABLE CISIS/STRESS POINTS
Ranking of Family Health Problem According to Priorities
Problem:
CRITERIA WEIGHT JUSTIFICATION
1, Nature of the Problem _ x 1
3
2. Modifiability of the problem _ x 2
2
3. Preventive Potentials _ x 1
3
4. Salience _ x 1
2
TOTAL =
Problem:
CRITERIA WEIGHT JUSTIFICATION
1, Nature of the Problem _ x 1
3
2. Modifiability of the problem _ x 2
2
3. Preventive Potentials _ x 1
3
4. Salience _ x 1
2
TOTAL =
Problem:
CRITERIA WEIGHT JUSTIFICATION
1, Nature of the Problem _ x 1
3
2. Modifiability of the problem _ x 2
2
3. Preventive Potentials _ x 1
3
4. Salience _ x 1
2
TOTAL =
RANK ACCORDING TO PRIORITIES
1.
2.
3.
