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 family’s ability to maintain a reciprocal relationship with the community and to determine if the
family is a closed or open system.
Strong connection
Church
Tenuous connection

Stressful connection

Reciprocal direction of
energy & resources

M F No connection /
participation (no line)
RHU/Hos
p

School
Neighbor

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: 3 Approx size of each sleeping room (sq m): ______ # of people occupying each room:
Lighting: Electricity: ̷ Kerosene lamp: __ x __ Rechargeable battery: __x____ Candle: _x_
Others, specify
Ventilation: Specify how many windows does each room have: ___3____
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 and rooms__________
Kitchen: Generally clean surroundings: __x__ Generally unclean: __̷__
Pots and pans washed and kept in cupboards __x__ Pots, pans, plates scattered and unclean __̷__
No flies/cockroaches/rats observed __x__ Flies/cockroaches/rats visible __̷__
Food storage (check as many as applicable)
Refrigerator: x
Food: closed: ̷ open: __x__
Pot/food keepers/plastic containers: with cover _̷_ without cover __̷__
None because all food is consumed every meal _̷_ Others (specify) __none___________________________
Presence of accident hazards (check as many as applicable)
Sharps unkempt: _x_
Medicine cabinet: Present: __x__ Absent: __̷__
With lock __x__ Where are medicines kept: _in the table___
Without lock _̷__
Where are poisons kept: ______________________________________________ ______________________________
Cooking facility: Gas range Gas stove __x__ Electric stove __x__
If gas stove or gas range: With safety device _x___ Without __x__
“Dirty kitchen”__ ̷__
With clean surroundings __ ̷__ With piled garbage/combustible debris near it __̷__

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 SAINT LOUIS UNIVERSITY
School of Nursing

Burning of food: Never occurred __x__ Seldom occurs _̷___ Commonly occurs __x__
Checking of stove before family members leave the house:
Not a practice _x___ Only a few members do this __x_ Consciously done by all members_x_
Electrical wiring checked annually: Yes __̷___ No ____
Attitude of members leaving sockets with plugs still connected: Yes __x__ No __̷__
Presence of stairs in the home: Yes _̷___ None __x__
If yes: with rails _̷___ None but necessary __x__ Not necessary _x_
Members walking barefoot:
When entering CR/bathroom: Yes _x_ No __̷__
When going outside the house: Yes _x_ No __̷__
Slippery floors: Present _̷___ None __x__
Domestic animals that bite: Present __x__ None __̷__
Highway in close proximity to the house: Yes _x___ No __̷__
Others (specify): __none____________________________________________________________________________________
Water supply:
Source: Level I (protected spring, deep well) _̷___ Level II _x__ Level III __x__ Others (specify) __x___
Ownership: Family-owned __x__ Shared with other families _̷___ How many families __whole___
Storage of drinking water (check as many as applicable):
Earthen jar: with cover __̷__ without cover __x__
Bottles / plastics: with cover _̷___ without cover __x__
Water dispenser: __x__ Others (specify): _________none__________ None __x__
Storage of water used for cooking:
Water tank: with cover __x__ without cover __x__
Drums: Plastic: _̷___ Tin drums _̷__
Others (specify) __none____________________________________________________________________________
Potability: Boiled _x___ Tested: Yes _x___ Not tested __̷__
If tested: When last tested ___x___________________ Who did the test _____x____
Results of test: _____________x_____________________________________________________________________
Domestic animals
Type of animal Number Check appropriate column
With cage Stray
Dog 1
Fowl (specify) 0
Cat 0
Pig 0
Others (specify) 0
Toilet facility:
Type: Level I __̷__ Level II _x___ Level III __x__
If open pit privy, specify location and distance from the kitchen
Ownership: Family-owned ̷ Public
Shared with other families __x__ How many families __x__
Sanitary condition: No smell __̷__ Foul-smelling _ X__ With flies _X___ No flies __x__
Garbage or refuse disposal:
Type: Landfill __̷__ Composting __x__ Burying __x__ Burning ___̷___
Open dumping ____ Location and distance from the house ____1 meters___________________________
Garbage collection: none Schedule of collection: none
Segregation of waste: Practiced by family Not practiced
Sanitary condition: No flies _x___ No smell _x___ With flies __̷__ With smell __̷__
Drainage system: Type: Closed/blind _̷ Open x None (directly to the ground): x
Drainage continuously flow x With stagnation of drainage: x
Sanitary condition: x Frequented by vectors ____ Not frequented by vectors ___̷__
2) KIND OF NEIGHBORHOOD
Rural ̷ Rurban x Urban x Slum area x
Distance of one house to another (approx in meters) Population density: __not taken____
Conclusion: Congested x Not congested ̷

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 SAINT LOUIS UNIVERSITY
School of Nursing

3) SOCIAL/RECREATIONAL AND GOVERNMENT FACILITIES

FACILITY CHECK IF DISTANCE FROM HOUSE FAMILY AWARENESS & UTILIZATION
PRESENT (approx in meters or kms) Check if family is Check if family
aware utilizes
Social / government facilities ̷ 4-km ̷
Day Care / Nursery ̷ 1-2km ̷
Elementary school ̷ 10-12 km ̷
High school X
Vocational school X
College X
DSWD X
DENR X
Others (specify)
Recreational facilities
Sports center
Others (specify)
Non-government agencies servicing the comty

People’s organization present in the community

4) HEALTH FACILITIES AND MANPOWER AVAILABLE

HEALTH FACILITY DISTANCE FROM TYPE & # OF MANPOWER FAMILY AWARENESS & UTILIZATION
HOUSE (approx in m AVAILABLE Check if family is Check if family
or in kms) aware utilizes
Barangay Health Station 2-6 km RHM ̷
Rural Health Unit 2-6 km ̷
Emergency / District Hospital 10-12 km
Others (specify) None None None None

5) COMMUNICATION FACILITIES
Phones: mobile X land phone __X__ radio __̷__ TV __̷__ computer X
Letter _X___ word of mouth _̷___ others (specify) ___________________________________________

6) TRANSPORTATION FACILITIES ON A 24-HOUR BASIS: None ____ Only hitch rides _̷_
Private car __x__ Taxi X PUJ X Van __̷__ Tricycle __x__ Passenger bus __x__

D. HEALTH STATUS OF EACH FAMILY MEMBER

 Obstetrical history
NAME OF CHILD AGE OF FREQUENCY OF PLACE OF DELIVERY TYPE OF REMARKS
(Listed by order of MOTHER PRENATAL CHECK Attendant at Just check if DELIVERY (NSVD, (Specify if alive or
arrangement in the family) WITH THIS UPS (eg: 1x every home hospital delivery LCCS, Assisted dead on
PREGNANCY mo, 3x during delivery – specify assessment. If
whole pregnancy, if with difficulty dead, specify
etc) or none) reason)
Edwin Bagsan Husband NSVD alive
Dominador Bagsan Husband NSVD alive
Gerico Bagsan Husband NSVD alive
Biba Bagsan Husband NSVD alive

 Family developmental stage:

Expected tasks:

VULNERABLE FAMILY WEIGHT HEIGHT MID-UPPER ARM FOOD PREFERENCES EATING/FEEDING

MEMBER CIRCUMFERENCE HABITS/PRACTICES
(for children only)

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 SAINT LOUIS UNIVERSITY
School of Nursing

 Dietary history indicating quality and quantity of food intake per day:
CONTENT & AMOUNT BREAKFAST LUNCH SUPPER
Usual content of food Rice + fish + vegetables Rice + fish + vegetables Rice + fish + vegetables
Amount of food intake
(average)
Risk assessment measures for obese members of the family
MEASURE / INDICATOR EXPECTED NORMAL FINDINGS ACTUAL FINDINGS
OBESE FAM MEMBER FINDINGS
Body mass index (BMI = wt in kgs / ht in m2) 18.6 to 22.9
Waist circumference <90 cm for men; <80 cm for women
Waist-hip ratio (WHR = waist circumference in Less than 1 cm in men; less than .85
cm/ hip circumference in cm cm in women
 Assessment of common risk factors leading to non-communicable diseases (check as many as applicable)
RISK FACTOR CHECK THOSE NON-COMMUNICABLE DISEASES WHEREBY FAMILY MEMBER/S ARE PREDISPOSED OF (pls
PRACTICED IN THE check appropriate column)
FAMILY 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 COMMUNICABLE DISEASE FOR WHICH FAMILY ARE PREDISPOSED OF
many risk (check as many as applicable)
factors PTB Other respiratory Dengue & other Diarrheal
present diseases mosquito-borne dis disease
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 Chief complaint Family beliefs as to causes Remedies done by family
member Medical consult to Home remedies Remarks
whom/where initiated
Tony HPN, Cough and colds Cold weather/ Genetics Home/RHU Amlodipine

Pauline HPN, Cough and colds Cold weather/ Genetics Home/RHU Amlodipine and
Losartan

 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 causes Remedies done by family
Home Hosp / consult Remarks
None

None

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 SAINT LOUIS UNIVERSITY
School of Nursing

 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
none
none
none
none

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

 BELIEFS AND PRACTICES OF PROMOTIVE & PREVENTIVE HEALTH SERVICES
 Immunization status of family members, especially children 0-8 years old and mothers of reproductive age (14-49 years old)
FAMILY MEMBERS BCG HBV OPV DPT AMV TT
1 2 3 1 2 3 1 2 3 1 2 3 4 5
Tony Bagsan x x x x x x x x X x x x x x x x
Pauline Bagsan x x x x x x x x X x x ̷ ̷ ̷ ̷ ̷
Edwin Bagsan ̷ ̷ ̷ ̷ ̷ ̷ ̷ ̷ ̷ ̷ ̷ x x x x x
Dominador Bagsan ̷ ̷ ̷ ̷ ̷ ̷ ̷ ̷ ̷ ̷ ̷ x x x x x
Gerico Bagsan ̷ ̷ ̷ ̷ ̷ ̷ ̷ ̷ ̷ ̷ ̷ x x x x x
Biba Bagsan ̷ ̷ ̷ ̷ ̷ ̷ ̷ ̷ ̷ ̷ ̷ x x x x x
 Reasons for submitting self or children for immunization: _________________________________________________________
________________________________________________________________________________________________________________
 Regular check ups
Family member Age Promotive / preventive services
Never goes Goes only Goes for Does Annual Dental Annua Stool Testic
for check up for check annual month PAP’s exam = 1- l eye guiac ular
even if ill up if ill PA ly SBE smear 2x a year exam test exam
Tony 71 x x X x x X x x
Pauline 65 x x X x x X x x
Edwin 48 x x X x x X x x
Dominador 44 x x X x x X x x
Gerico 42 x x X x x X x x
 Practice of family planning methods (applicable for married couples of reproductive age or MCRA = 14-49 years old)
FP acceptor: x FP user: x FP Non-acceptor _̷___
Method accepted: x Method being used: none
Reason for acceptance and use: ______________________________________________________________________________
Reason for non-acceptance / non-use:_natural method_________
Misconceptions heard about the use of FP: _____none___________________________________________________________
________________________________________________________________________________________________________
 VALUES, HABITS AND PRACTICE OF OTHER HEALTH LIFE STYLES
 Exercise, rest and sleep
Family Rest and sleep Exercise Relaxation Stress
members # of hours Interrupted Naps Naps Nature of Frequ # of activities management
per night or present absent exercise ency minutes activities
continuous per per employed
week exercise
Tony 7 continous ̷ Brisk walk 7 30 mins Sleeping, Sleeping, resting
Pauline 7 continous ̷ 7 30 mins resting
Edwin 8 continous ̷ 7 30 mins
Dominador 8 continous ̷ 7 30 mins
 Beliefs and practices about nutrition during menstruation, pregnancy, childbirth, illness, feeding babies, etc.
Menstruation: ___none_____________________________________________________________________________________
Pregnancy: _____________________________________________________________________________________________
Childbirth: ____none_______________________________________________________________________________________
Feeding babies: ___none____________________________________________________________________________________
Illness: __________________________________________________________________________________________________
Others: ________________________________________________________________________________________________

- End of questionnaire –
Prepared by: Core Group on NCP and FNCP Formats, School of Nursing, October 2010)

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