INITIAL DATA BASE

Date Interviewed:
Head of the Family: Family No.:
Address:
Type of Family Structure:

A. Family Structure and Characteristics

Family
Member Name Relation to Sex Age Marital Highest Educational Occupation Health Remarks
No. Head Status Attainment Type of Work Place
 INITIAL DATA 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

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5.) Dominant Family Members in matter of health care

6.) General Family Relationship

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B. Social-Economic and Cultural Factors

1.) Income Expenses
a. Occupation place of work and income of each working member
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b. Adequacy to meet basic necessities (food, clothing, and shelter)

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c. Who makes decision about the money and how it is spent?

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2.) Educational Attainment of each member

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3.) Ethnic background and religious affiliation

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4.) Significant Others

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5.) Relationship of the Family to Larger Community

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C. Environmental Factors

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. Lightning 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: __________
( ) Basal in Pit
b. Toilet
1.) Type
( ) None ( ) Antipolo System
( ) Pail System ( ) Water-sealed Latrine
( ) Open pit privy ( ) Flush Type
( ) Closed pit privy ( ) Overhung latrine
( ) Bored-hole latrine ( )Others Specify: __________
2.) Distance from the house: _______________________________________
3.) Sanitary Condition: ____________________________________________

5. Domestic Animals
Kind Number Where Kept
_______________ _______________ _______________
_______________ _______________ _______________

6. The Community in General

a. General Sanitary Condition: _______________________________________
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b. Housing Congestion: ( ) Yes ( ) No
c. Recreational Facilities: ___________________________________________
d. Availability of Health Care Facilities (Describe briefly) _________________
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e. Distance from the house to the nearest health care facilities: ___________
D. Health Assessment of each Member
1. Medical and Nursing History indicating illness, conducive to illness.
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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
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c. Eating/ Feeding habit/ Practices
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3. Current Health Status Indicating Presence of Illness States

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E. Valued Placed on Prevention of Disease

1. Immunization State of Children
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2. Use of other preventive services
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