SAINT LOUIS UNIVERSITY

School of Nursing

RELATIONSHIP OF THE FAMILY TO THE LARGER COMMUNITY: Connect the family to the different aspects of
the community using the legend below in order to determine the familys ability to maintain a reciprocal
relationship with the community and to determine if the family is a closed or open system.
Strong connection

Tenuous connection

Churc
h
Orgn
activit
y

Stressful connection

Et
c

Reciprocal direction
of energy & resources

M
RHU/H
osp

Comty
activit
y

Et
c

No connection /
participation (no line)

Et
c
Scho
ol

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SAINT LOUIS UNIVERSITY

School of Nursing
C. HOME
AND ENVIRONMENT (Use OBSERVATION only as method of data gathering if at all
possible.
Supply data with words, , X or NA or not applicable. Do not leave any blank as this
will mean not assessed).
1) HOUSING
Owned: ______
Rented: ______
Total # of rooms of house: ______
Approx size of each sleeping room (sq m): ______ # of people
occupying each room: _____
Lighting: Electricity: ______
Kerosene lamp: ______
Rechargeable battery: ______
Candle: ______
Others, specify ________________________________
Ventilation: Specify how many windows does each room have: _______
Type of materials used:
Light (bamboo, nipa, etc): _____ Mixed (combination of wood, GI, cement): _____ Permanent/strong
(cement): _____
Others (please specify): ______________________________________________
Presence of breeding/resting places of vectors (roaches, flies, mosquitoes, rats, etc.): None observed:
_______
Present: ______ Location (pls specify kitchen, garbage inside the kitchen, etc.):
__________________________________
Kitchen: Generally clean surroundings: ____
Generally unclean: ____
Pots and pans washed and kept in cupboards ____
Pots, pans, plates scattered and
unclean ____
No flies/cockroaches/rats observed ____
Flies/cockroaches/rats visible ____
Food storage (check as many as applicable)
Refrigerator: ____
Food cabinet: closed ____
open: ____
Pot/food keepers/plastic containers: with cover ____
without cover ____
None because all food is consumed every meal ____
Others (specify)
______________________________________
Presence of accident hazards (check as many as applicable)
Sharps unkempt:____
Medicine cabinet:
Present: ____
Absent: ____
With lock ____
Where are medicines kept ____
Without lock ___
Where are poisons kept:
________________________________________________________________________________
Cooking facility:
Gas range ____
Gas stove ____
Electric stove ____
If gas stove or gas range:
With safety device ____ Without ____
Dirty kitchen____
With clean surroundings ____
With piled garbage/combustible debris near it ____
Burning of food:
Never occurred ____
Seldom occurs ____
Commonly occurs ____
Checking of stove before family members leave the house:
Not a practice ____
Only a few members do this ____
Consciously done by
all members ____
Electrical wiring checked annually: Yes ____
No ____
Attitude of members leaving sockets with plugs still connected: Yes ____
No ____
Presence of stairs in the home: Yes ____
None ____
If yes: with rails ____
None but necessary ____
Not necessary __
Members walking barefoot:
When entering CR/bathroom: Yes ____
No ____
When going outside the house: Yes ____
No ____
Slippery floors: Present ____
None ____
Domestic animals that bite:
Present ____
None ____
Highway in close proximity to the house: Yes ____
No ____
Others (specify):
_______________________________________________________________________________________
Water supply:
Source: Level I (protected spring, deep well) ____
Level II ___
Level III ____
Others
(specify) __________
Ownership: Family-owned ____ Shared with other families ____ How many families _____
Storage of drinking water (check as many as applicable):
Earthen jar: with cover ____
without cover ____
Bottles / plastics: with cover ____
without cover ____
Water dispenser: ____
Others (specify): ____________________ None ____
Storage of water used for cooking:
Water tank: with cover ____
without cover ____
Drums: Plastic ____
Tin drums ____
Others (specify) ____________________________________________________________________

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SAINT LOUIS UNIVERSITY

School of Nursing

Potability: Boiled ____

Tested: Yes ____
Not tested ____
If tested: When last tested ______________________
Who did the test ______________________________
Results of test: _______________________________________________________________________________
Domestic animals
Type of animal

Number

Check appropriate column

With cage
Stray

Dog
Fowl (specify)
Cat
Pig
Others (specify)
Toilet facility:
Type:

Level I ____
Level II ____
Level III ____
If open pit privy, specify location and distance from the kitchen
_________________________________________
Ownership: Family-owned ____
Public ____
Shared with other families ____ How many families ____
Sanitary condition: No smell ____
Foul-smelling ____
With flies ____
No flies ____
Garbage or refuse disposal:
Type: Landfill ____
Composting ____
Burying ____
Burning ____
Open dumping ____
Location and distance from the house
_____________________________________
Garbage collection _____
Schedule of collection
__________________________________________________
Segregation of waste: Practiced by family ____
Not practiced ____
Sanitary condition: No flies ____
No smell ____ With flies ____ With smell ____
Drainage system: Type:
Closed/blind ____
Open ____
None
(directly to the ground) ____
Drainage continuously flow ____
With stagnation of
drainage ____
Sanitary condition:
Frequented by vectors ____
Not
frequented by vectors ____
2) KIND OF NEIGHBORHOOD
Rural ____
Rurban ____
Urban ____
Slum area ____
Distance of one house to another (approx in meters) ______________
Population density: ______
Conclusion: Congested ____
Not congested ____
3) SOCIAL/RECREATIONAL AND GOVERNMENT FACILITIES
FACILITY

CHECK IF
PRESENT

DISTANCE FROM
HOUSE
(approx in meters or
kms)

FAMILY AWARENESS & UTILIZATION

Check if family is
Check if family
aware
utilizes

Social / government facilities

Day Care / Nursery
Elementary school
High school
Vocational school
College
DSWD
DENR
Others (specify)
Recreational facilities
Sports center
Others (specify)
Non-government agencies servicing the
comty
Peoples organization present in the
community

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SAINT LOUIS UNIVERSITY

School of Nursing

4) HEALTH FACILITIES AND MANPOWER AVAILABLE

HEALTH FACILITY
DISTANCE FROM TYPE & # OF MANPOWER
HOUSE (approx
AVAILABLE
in m or in kms)

FAMILY AWARENESS &

UTILIZATION
Check if family
Check if family
is aware
utilizes

Barangay Health Station

Rural Health Unit
Emergency / District
Hospital
Others (specify)
5) COMMUNICATION FACILITIES
Phones: mobile ____
land phone ____
Letter ____
word of mouth ____
_______________________________________

radio ____
TV ____
others (specify)

6) TRANSPORTATION FACILITIES ON A 24-HOUR BASIS: None ____

Private car ____
Taxi ____
PUJ ____
Passenger bus ____

computer ____

Only hitch rides ____

Van ____
Tricycle ____

D. HEALTH STATUS OF EACH FAMILY MEMBER

Obstetrical history
NAME OF CHILD
(Listed by order of
arrangement in the
family)

FREQUENCY OF
PRENATAL
CHECK UPS
(eg: 1x every
mo, 3x during
whole
pregnancy, etc)

PLACE OF DELIVERY
Attendant at
Just check if
home
hospital
delivery

TYPE OF
DELIVERY
(NSVD, LCCS,
Assisted
delivery
specify if with
difficulty or
none)

REMARKS
(Specify if alive
or dead on
assessment. If
dead, specify
reason)

Family
developmental
stage:
_____________________________________________________________________________________
Expected
tasks:
________________________________________________________________________________________________
Developmental assessment of infants, toddlers and preschoolers through the MMDST (separate assessment
tool)
Nutritional assessment of vulnerable family members (infants, children, pregnant, post-partum mothers,
sick members & members with clinical manifestations of thinness or undernourished)
VULNERABLE FAMILY
MEMBER

AGE OF
MOTHER
WITH
THIS
PREGNAN
CY

WEIGHT

HEIGHT

MID-UPPER ARM
CIRCUMFERENCE
(for children only)

FOOD PREFERENCES

EATING/FEEDING
HABITS/PRACTICES

Dietary history indicating quality and quantity of food intake per day
CONTENT & AMOUNT
Usual content of food

BREAKFAST

LUNCH

SUPPER

Amount of food intake

(average)

Risk assessment measures for obese members of the family

MEASURE / INDICATOR
Body mass index (BMI = wt in kgs / ht
in m2)
Waist circumference

EXPECTED NORMAL FINDINGS

ACTUAL FINDINGS
OBESE FAM MEMBER
FINDINGS

18.6 to 22.9
<90 cm for men; <80 cm for

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SAINT LOUIS UNIVERSITY

School of Nursing
Waist-hip ratio
(WHR = waist circumference in cm/ hip
circumference in cm

women
Less than 1 cm in men; less
than .85 cm in women

Assessment of common risk factors leading to non-communicable diseases (check as many as applicable)
RISK FACTOR

CHECK THOSE
PRACTICED IN
THE FAMILY

NON-COMMUNICABLE DISEASES WHEREBY FAMILY MEMBER/S ARE

PREDISPOSED OF (pls check appropriate column)
CVD
DM
CANCER
RESP CONDITION

Alcohol intake
Blood glucose level, elevated
Blood
lipids/cholesterol,
elevated
Blood pressure, elevated
Family history of cancer, DM,
HPN, etc
Inadequate fiber intake
Nutrition/diet, poor
Obesity
Physical inactivity
Sedentary life style
Smoking cigarette or tobacco

Assessment of risk factors leading to common communicable diseases (check as many as applicable)
Possible risk factors

Check as
many risk
factors
present

COMMUNICABLE DISEASE FOR WHICH FAMILY ARE

PREDISPOSED OF
(check as many as applicable)
PTB
Other
Dengue & other
Diarrheal
respiratory
mosquito-borne
disease
diseases
dis

Exposure to a suspect/registered TB case

Exposure to a respiratory-related CD
Lives in a known dengue-infected area
Does not regularly practice the following
habits:
Changing H2O/scrubbing sides of flower
vases
Not cleaning surroundings
Non-disposal or rubber tires, empty
bottles & cans
Not keeping water containers covered
Too many hanging clothes inside the house
Poor environmental sanitation
Non-potable water supply
Unsanitary food sources, preparation and
serving
Fond of eating street foods
Malnourished

Focused assessment results of vulnerable family members indicating presence of illness states
Vulnerable
member

Chief complaint

Family beliefs as to
causes

Remedies done by family

Medical consult to
Home remedies
whom/where
initiated

Remarks

Medical and nursing history indicating current or past significant illnesses or beliefs and practices conducive
to health and illness
Family member
Past illness
Beliefs as to
Remedies done by family
causes
Home
Hosp / consult
Remarks

Results of laboratory/diagnostic or screening procedures undergone by vulnerable family members

Family member
Laboratory/diagnostic/screening procedure
Procedure done
Expected normal findings
Actual findings

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SAINT LOUIS UNIVERSITY

School of Nursing

E. VALUES, HABITS, PRACTICES ON HEALTH PROMOTION, MAINTENANCE AND DISEASE PREVENTION

BELIEFS AND PRACTICES OF PROMOTIVE & PREVENTIVE HEALTH SERVICES

J Immunization status of family members, especially children 0-8 years old and mothers of
reproductive age (14-49 years old)
FAMILY MEMBERS
BC
HBV
OPV
DPT
AM
TT
G
V
1
2
3
1 2 3 1 2 3
1 2 3 4 5

J
J

Reasons
for
submitting
self
or
______________________________________________________
Regular check ups

Family member

Ag
e

Never
goes for
check up
even if ill

Goes
only for
check up
if ill

children

for

Promotive / preventive services

Goes
Does Annua
Dental
for
mont
l
exam =
annual
hly
PAPs
1-2x a
PA
SBE
smear
year

immunization:

Annu
al
eye
exa
m

Stoo
l
guia
c
test

Testi
cula
r
exa
m

Practice of family planning methods (applicable for married couples of reproductive age or MCRA =
14-49 years old)
FP acceptor: ____
FP user: ____
FP
Nonacceptor ____
Method acceptesd: ____________________ Method being used: _______________
____
Reason
for
acceptance
and
use:
__________________________________________________________________________
Reason
for
non-acceptance
/
non-use:
_____________________________________________________________________
Misconceptions
heard
about
the
use
of
FP:
_________________________________________________________________

VALUES, HABITS AND PRACTICE OF OTHER HEALTH LIFE STYLES

J Exercise, rest and sleep
Family
members

# of
hour
s per
night

Rest and sleep

Interrupte
Naps
d or
present
continuou
s

Naps
absent

Nature of
exercise

Exercise
Frequenc
y per
week

# of
minutes
per
exercise

Relaxatio
n
activities

Stress
manageme
nt activities
employed

Beliefs and practices about nutrition during menstruation, pregnancy, childbirth, illness, feeding
babies, etc.

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SAINT LOUIS UNIVERSITY

School of Nursing
Menstruation:
_________________________________________________________________________________________
Pregnancy:
___________________________________________________________________________________________
Childbirth:
____________________________________________________________________________________________
Feeding
babies:
_______________________________________________________________________________________
Illness:
_______________________________________________________________________________________________
Others:
______________________________________________________________________________________________
- End of questionnaire
Prepared by: Core Group on NCP and FNCP Formats, School of Nursing, October 2010)

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