VISION MISSION

Republic of the Philippines Cavite State University shall provide

A premier university in historic
Cavite recognized for excellence in
the development of morally upright
and globally competitive
individuals.
CAVITE STATE UNIVERSITY excellent, equitable and relevant
educational opportunities in the arts,
Don Severino De las Alas Campus science and technology through
Indang, Cavite quality instruction and relevant
research and development activities.
It shall produce professional, skilled
College of Nursing and morally upright individuals for
global competitiveness.

Initial Data Base for Family Nursing Practice

FAMILY STRUCTURE, SOCIO – ECONOMIC AND CULTURAL

CHARACTERISTICS

HEAD of the Family (Namumuno sa buong pamilya): ___________________________

Barangay (Purok):
Address (Tirahan):

Name of Members Position Age Sex Civil Status Ethnic Religion Education Occupation
(Pangalan ng bawat (Posisyon sa (Edad) (Kasarian) Background (Relihiyon) (Edukasyon) (Trabaho)
miyembro) pamilya) (Lahi)

Type of Family (Klase ng pamilya): A. nuclear extended others specify:

B. Patriarchal Matriarchal
C. Who decides in the family especially in matters of health care? (Sino ang nagpapasya sa loob ng pamilya
lalo na kung tungkol sa kalusugan?): _____________________________________________________

D. General family relationship / dynamics (Pangkalahatang ugnayan o relasyon sa loob ng pamilya):

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

E. Siginificant others and role (s) they play in the family’s life. (Mga importanteng tao at ang kanilang
ginagampanan sa buhay pamilya)
1. _________________________________________ 3. ________________________________________
2. _________________________________________ 4. ________________________________________

F. Relationship of the family to the larger community (Relasyon ng pamilya sa pamayanan?)

__________________________________________________________________________________________

Type of Occupation (Uri ng hanapbuhay): Blue Collar Job White Collar Job
Status of Employment Regular Company Employee Contractual Employee
 Self – employed
Place of Occupation (Lugar ng hanapbuhay): _____________________________________________
Monthly Income (Kita sa isang buwan): _________________________________________________
Everyday expenses (Gastusin sa isang araw): _____________________________________________

Who decides about money and how is it spent? (Sino ang nagdedesisyon kung paano gagamitin ang pera?)
____________________

Adequacy to meet basic necessities (Naibibigay ang lahat ng pangagailangan)

 Pagkain  Yes (Oo)  No (Hindi)
 Damit  Yes (Oo)  No (Hindi)
 Tirahan  Yes (Oo)  No (Hindi)

HOME AND ENVIRONMENTAL FACTORS

I. Housing
a. House ownership (Pag – aari ng tahanan)  Owned (Pahg – aari)  Rented (Inuupahan)
 Rented Free (Walang Bayad)
b. Type of house ( uri ng tahanan):  Concrete  Light

 Mixed (Halo)  Makeshift

c. Power Source (Pinagkukunan ng kuryente / ilaw):

 with electricity (may kuryente)  w/o electricity (walang kuryente)

 kerosene  others (iba) specify: __________

d. Food storage and cooking facilities
1. Food storage  ice box/ cooler  refrigerator  others specify: _________

2. Cooking facility (Lutuan):  gas stove  electric stove  wood/ charcoal

 Others (iba) specify:

3. With cleaning facility  faucet w/ running water and sink  pail w/ water and sink
 Pail w/ water and open pit

e. Water Source / supply (pinagkukunan ng tubig)

Ownership (pag – aari)  owned (pag – aari)  Public (pampubliko)

Water for general use  NAWASA / LWUA  artesian well (poso)

 Deep well (balon)  others (Iba) specify: _________

Drinking water supply  NAWASA / LWUA  artesian well (poso)

 Deep well (balon)  others (Iba) specify: _________

 Potability :  Potable  Not Potable

Distance from the house: ________________________________________

Drinking storage (Inumin):  None (direct from faucet or pipe)  Large covered without faucet

 Large covered container with faucet  others, specify ____________

f. Presence of breeding or resting sites of vectors of disease

Are there breeding or resting sites of vectors of disease?  Yes  No

Which of the following are present in your house?  mosquito  flies

 cockroach  rodent
g. Presence of accident hazards
Are there any of the following:  broken stairs  pointed objects (please specify) ______
 poisons  fire hazards
 fall hazards  improperly kept medicines
 others (specify) ______________________
h. Toilet facility (Palikuran):
LEVEL I  Pit latrines  reed odorless earth closet  pour flush toilet  aqua privy
LEVEL II  Flush type water sealed toilet with septic tank
LEVEL III  Flush type water sealed toilet sewerage system/ treatment plant

If without a toilet, please specify method of excreta disposal: _______________________

Distance from house: __________________________________________________________________

General description of excreta disposal  Sanitary  Unsanitary

i. Garbage/ Refuse disposal (Pagtatapon ng basurang nabubulok at di – nabubulok)

a. Use garbage or refuse containers  Yes  No
1. Refuse disposal (basurang nabubulok)  Covered container  Open container
2. Garbage disposal (Di – nabubulok)  Covered container  Open container
b. Use method of segregation  Yes  No
c. Method of disposal:
 hog feeding  open burning  open dumping
 burial in pit  composting  garbage collection
 others, specify
j. Drainage system (Kanal)
With drainage system  Yes  No
 Type:  Blind Canal  Covered Canal System  Open Canal System

k. Domestic Animals

 Dog (#__)  Cat (#__)  Birds (#__)  Pig (#__)

Disposal of Animalo Waste  Sanitary  Unsanitary

II. Neighborhood

Kind of Neighborhood (uri ng komunidad):  congested ( dikit – dikit)  not congested (hindi dikit – dikit)

 troublesome (magulo)  peaceful (tahimik)

 others specify: _____________________

Is it safe to go out at night? (Delikado ba lumabas sa inyong lugar kapag gabi?)  Yes  No

If there is trouble in the neighborhood, how often does it happen? (Kung magulo, gaano kadalas ang
kaguluhang nangyari?) :

 daily  weekly  monthly

III. Social and Recreational Facilities

A. Recreational Facilities  malls  movie houses  parks (Parke / liwasan)

 others (iba) specify: ________________

How often do you go out? (Gaano kayo kadalas lumalabas para makapaglibang?)  once a week

 twice a week  3 times or more

B. Social Facilities (Lugar ng pagpupulong / salu – salo)  court (payo)  Brgy. Hall

 others specify: ______________

Do you get involved in the community? (Sumasali ba kayo sa mga pagpupulong / salu – salo?)

_________________________________________________________________

IV. Communication and Transportation

Communication

Method:  Informal  Formal

Type:  Public Announcement  Community Bulletin  Brgy. Assembly
Facilities:  Telephone/ Cellphone  Postal Mail (Koreo)
 Internet  Others (Iba) Specify: ________________

Forms of Transportation:  owned vehicle pls. specify ___________  Commute

 If Commute, what is the major type used in the barangay:
 jeep  tricycle  bus  others (Iba) specify: ____________________
 Around the community  jeep  tricycle  bus  others (Iba)
Specify:
 Outside of the community  jeep  tricycle  bus  others (Iba)
Specify:

HEALTH AND MEDICAL HISTORY

PAST ILLNESS (Nakaraang sakit)

Name of the family Age (Gulang) Disease Medical Attendant Medications and
members (pangalan (sakit/ karamdaman) Treatments received
ng miyembro) (natanggap na
lunas)

PRESENT ILLNESS (Kasalukuyang Sakit)

Name of the family Age (Gulang) Disease Medical Attendant Medications and
members (pangalan (sakit/ karamdaman) Treatments received
ng miyembro) (natanggap na
lunas)
FAMILY MEDICAL HISTORY
Genetic disposition (hereditary diseases) Mga namamanang sakit

Mother side
 Diabetes  Hypertension  Cancer  Asthma  Others
Specify _________________
Father Side
 Diabetes  Hypertension  Cancer  Asthma  Others
Specify _________________

HOSPITALIZATION:

Name of the family Age Reason Length of Operation (If any)

member (Pangalan (Gulang) Confinement
ng miyembro) (Tagal ng pagtigil)

VALUES, HABITS, PRACTICES ON HEALTH PROMOTION, MAINTENANCE, AND

DISEASE PREVENTION

IMMUNIZATION STATUS (Under 5 yrs. Old)

Name of the family

member (Pangalan ng Age Vaccines Remarks
miyembro) (Gulang)

Vaccines (CHOICES)
Remarks (CHOICES):
BCG DPT OPV Hepatitis B Measles Others pls. specify
Complete Incomplete

MEDICAL CARE

Consultation:  Goes for check – up even without illness.

 Goes for check – up only when ill or have signs and symptoms
 Facility Used:  Health Center  Hospital  Clinics
 Private Physicians  Faith Healer (albularyo)
 Other specify: _________________________
Medical Practitioner often consulted:
 Medical Doctor  Dentist  Nurse
 Midwife  Faith Healer  Herbularyo  Hilot
How far is it from your house from the medical facility?

(Gaano kalayo mula sa inyong bahay?) _________ (km)

NUTRITIONAL ASSESSMENT

Infant Feeding Practices

Boils water for infant formula  Yes  No

Nutritional Assessment (Adult) Nutritional Assessment (Child)

Name of the Name of the Age Height Weight Remark

family member BMI Remark family member
(Pangalan ng (Pangalan ng
miyembro) miyembro)

Family planning

Name of the family member Age (Gulang) Methods of Contraception Recipient

(Pangalan ng miyembro)

Method of Contraception (CHOICES)

Rhythm Condom IUD Withdrawal Ligation Vasectomy Others pls. specify

DENTAL CARE

Name of the family member Age (Gulang) Methods of Contraception Recipient

(Pangalan ng miyembro)
Dental Health Status (CHOICES) Remarks
(CHOICES)
With dentures With braces With retainer With fillings Other status specify: Complete Incomplete

How many times does the family brush their teeth?

_________________________________________________
How often does the family go to the dentist?
______________________________________________________

MATERNAL AND CHILD

MATERNAL CARE: (for pregnant woman and postpartum)

Name of the family member Age Stage Recipient Remarks

(Pangalan ng miyembro) (Gulang)
Pre – natal  check – ups no. of check – ups
_______
Labor and  no. of delivery
delivery
 complication specify:
Postpartum __________________

Postnatal  occurrence of problems

 check ups no. of check – ups

________

Pre – natal  check – ups no. of check – ups

_______
Labor and  no. of delivery
delivery
 complication specify:
Postpartum __________________

Postnatal  occurrence of problems

 check ups no. of check – ups

________

Nakunan na ba kayo? Ilang beses? ___________________________________

CHILD CARE: (for children below 5 years old)

Name of the family Age Infant Feeding Type of Milk Remarks
member (Pangalan (Gulang)
ng miyembro)
 breastfed  condensed Age Supplemental
 bottle - fed  evaporated Feeding started: ___
 powdered Specify: _________
 breast milk
 others
 Specify:
_______
 breastfed  condensed Age Supplemental
 bottle - fed  evaporated Feeding started: ___
 powdered Specify: _________
 breast milk
 others
Specify:
_______
 breastfed  condensed Age Supplemental
 bottle - fed  evaporated Feeding started: ___
 powdered Specify: _________
 breast milk
 others
Specify:
_______