Initial Data Base for Family Nursing Practice

The purpose of this survey tool is to identify past and current life styles, so that we may understand and
serve you better. The objective is to improve the services that we provided as the student we the help of
our CI, and to provide as a clear picture of/identify your current or future problem. The student would like
to involve you in as much of your care as possible. In order to understand your needs, I would appreciate
if you would assist me in completing this survey. This information will be used to assist us in implementing
services/programs that will be beneficial to you. Thank you for your assistance.

Family Name:

Address:

Household No.: Barangay Household No.:

I. Family Structure, Characteristics, and Dynamics

A. Family Data

a. Length of residency:
b. Place of origin:
c. Family size:
d. Religion:

B. Family Member’s Chart

A S POSITION
RELATIONSHIP EDUCATIONAL
FAMILY MEMBER G E CIVIL STATUS IN THE OCCUPATION
TO FAMILY HEAD ATTAINMENT
E X FAMILY

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 C. Family Structure

Type
a. Extended: b. Nuclear:
a. Matriarchal: b. Patriarchal:
Others:

Dominant Family Member:

D. General Family Relationship / Dynamics

CRITERIA STATUS Additional Information

Observable conflicts between

the family members

Characteristic of communication

Interaction patterns among

members

II. Socio-economic and Cultural Characteristics

A. Income and Expenses

a. Monthly Family Income Source

FAMILY MEMBER OCCUPATION PLACE OF WORK INCOME

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Total Family Income per
Month
 a. Below P 999.00 e. Above P 10.000.00 – 12,999.00
b. Above P 1,000.00 – 3,999.00 f. Above P 13,000.00 – 15,999.00
c. Above P 4,000 – 6,999.00 g. Above P 16,000 – 18,999.00

d. Above P 7,000.00 – 9,999.00 h. more than P 19,000.00

B. Who makes decisions about money?

______________________________________________________________________
________________________________________

C. Felt Family Needs (identify and rank according to priority)

1. 6.

2. 7.

3. 8.

4. 9.

5. 10.

III. Home and Environment

A. Housing

a. Is your lot owned?

Yes

No

b. Is your house owned?

Yes

No

c. Type of housing materials

Wood Concrete

Mixed Makeshift

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 Others, specify _______________________________________

d. Is the Living Space Adequate?

Yes

No

e. How was sleeping arrangement?

Adequate

Not

f. What are the appliances owned by the family?

______________________________________________________________________
________________________________________

g. Common household pests found at home

______________________________________________________________________
________________________________________

h. Pets / animal kept in the yard / home

______________________________________________________________________
________________________________________

i. Are there breeding sites or resting sites of vectors of diseases (eg. rodents,
mosquitoes, roaches, flies, etc)? What kind?

Yes

No

_____________________________________________________________________
_________________________________________

j. Are there accident hazards present? What kind?

Yes

No

_____________________________________________________________________
_________________________________________

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k. Food Storage and Cooking Facilities

Cooking

Electric Stove

Stove (LPG)

Brick Oven “pugon”

Storage

Covered Uncovered

Refrigerator Cabinet

Pots, Pan, etc

l. Water Supply

Type

Open Close

Source

Owned Bought

Shared

Others, specify _______________________________________

Storage

Covered Uncovered

Refrigerated

Containers used

Plastic pitchers Jars, Clay pots

Bottles

Others, specify _______________________________________

m. Toilet Facility

Type
Flush Wrap and Throw
Water – Sealed Pit Privy

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 Others, specify _______________________________________

Ownership
Owned Shared

Sanitary Condition
__________________________________________________________
______________________________________.

n. Garbage / Refuse Disposal

Type
Collected Burning
Waste Segregation Burying
Feeding to animals Throw in the river or sewer
Open Dumping

Others, specify _______________________________________

Sanitary Condition
__________________________________________________________
______________________________________.

B. Kind of Neighborhood

(eg. Slum, Congested)

________________________________________________________________
___________________________.

C. Social and Health Facilities Available

(eg. School, RHU)

________________________________________________________________
___________________________.

D. Communication

(eg. Cellphone, Snail Mail, E-mail)

________________________________________________________________
___________________________.

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 D. Transportation

(eg. Tricycle, Jeepney / Private, Public)

________________________________________________________________
___________________________.

IV. Values, Habits, Practices on Health Promotion, Maintenance

and Disease Prevention

A. Common illnesses encountered for the last 6 months and treatment

applied.

ILLNESS TREATMENT APPLIED

B. Whom do you consult for health – related problems?

Manghihilot Herbolario

Midwife Nurse

Doctor Health Center

BHW

Others, specify _______________________________________

C. For problems other than health, whom do you consult?

Family Members Relatives

Friends Barangay Officials

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 Priest

Others, specify _______________________________________

D. Have you had adequate:

1. Rest and sleep? Yes No

2. Exercise? Yes No

3. Relaxation activities? Yes No

4. Stress management activities? Yes No

5. Use of Protective Measure?

______________________________________________________________________
_____________________.

E. Use of Promotive-Preventive Health Sevices

(eg. Regular check-up in RHU, immunizations, etc)

________________________________________________________________
________________________________________________________________
________________________________________________________________
_____________.

V. Awareness of community organization

A. Are you aware of existing organizations in the community?

Yes

No

B. Name of the Organization/s you know

________________________________________________________________
________________________________________________________________
________________________________________________________________
_____________.

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 C. Are you a member of any of these organizations?

Yes

No

________________________________________________________________
_________________.

D. Are you aware of its activities and projects?

Yes

No

E. Name of 5 formal and non-formal leaders of the community whom you

think can led the people.

1.

2.

3.

4.

5.

*Health Status of each Family Member (which includes nutritional assessment,

Risk Factor Assessment, Physical assessment) is excluded in this copy.