Bulacan State University City of Malolos College of Nursing ASSESSMENT DATA BASE (per Family) Address: _______________________________ Informant:

_____________________________ Surveyed by: ________________________________ Date: ___________________

A. Family Structure, Characteristics and Dynamics/Relational Patterns 1. Members of the household: No. NAME OF FAMILY MEMBERS RELATION-SHIP TO THE HEAD Position in the family SEX AGE MO. BIRTHDATE YR. CIVIL STATUS

Total 2. Sociodemographic data of members not currently living in the household but with major role in resource generation use. No. NAME OF FAMILY MEMBERS RELATION-SHIP TO Position in the SEX AGE THE HEAD family

BIRTHDATE MO. YR.

CIVIL STATUS

Total 3. Type of family: ( ( ( ) nuclear ) matriarchal ) patrilocal ( ( ( ) extended ) patriarchal ) matrilocal ( ( ( ) single parent ) egalitarian ) neolocal ( ( ) Dyad ) matricentric ( ( ) homosexual ) patricentric ( ) cohabiting/common-law

4. Dominant family members in terms of decision making on matters of health and care tending: ( ) father ( ) mother ( ) both ( ) family ( ) others 5. Family dynamics, communication pattern/s, interactional processes and interpersonal relationship: 1. Presence of any obvious/readily observable conflict between members ( ) with ( ) none 2. How do the family discuss issues/concerns/conflict that may affect family relationship? ( ) Discusses about it and father decides on the issue/concern ( ) Discusses about it mother decides on the issue/concern ( ) both parent openly discuss and decides on the issue ( ) all family members discuss and decides on the issue/concerns ( ) involves significant others ( ) no discussion at all B. Socio-economic, and cultural Characteristics 1. Social Characteristics No. NAME OF FAMILY MEMBERS RELIGION

HIGHEST EDUCATION COMPLETED (6 years above)

OCCUPATION

PLACE OF ORIGIN

LENGTH OF RESIDENCE

Total 2. Monthly family income (combined) ( ) less than 5,000 ( ) 5,000 10,000 ( ) 10,001 15,000 ( ) 15,001 20,000 ( ) 20,001 25,000 ) 25,001 30,000 ) 30,001 35, 000 ) 35,001 40,000 ) 40,001 45,000 ) 45,001 50,000

( ( ( ( (

) 50,001 and above

3. Financial Source for Family Expenditures ( ) employment ( ) business ( ) pension ( ) help from relative/friends ( ) others: _______________ 4. Monthly family expenditure ( ) less than 5,000 ( ) 25,001 30,000 ( ) 50,001 and above ( ) 5,000 10,000 ( ) 30,001 35, 000 ( ) 10,001 15,000 ( ) 35,001 40,000 ( ) 15,001 20,000 ( ) 40,001 45,000 ( ) 20,001 25,000 ( ) 45,001 50,000 5. Priorities and Expenditure ( familys priority by ranking 1-7 where 1 is the highest priority ) ( ) food ( ) clothing ( ) education ( ) utilities ( ) health ( ) recreation ( ) savings 6. Decision maker in terms of financial aspect ( ) father ( ) mother ( ) both ( ) family ( ) others 7. Adequacy of family income: ( ) adequate ( ) not adequate 8. Cultural Characteristics A. Cultural orientation regarding illness ( ) believe that illness is caused by physiologic factor e.g. infection ( ) believe that illness is caused by supernatural phenomenon e.g. kulam, balis ( ) believe that illness is a punishment from God ( ) believe that illness is caused by other person ( ) believe that illness is caused by change in weather ( ) others: __________ B. Cultural belief: ( ) health can be restored by God/ other spiritual faith ( ) health can be restored by faith healers ( ) health can be restored by supernatural power e.g. Tawas, hilot, hula ( ) health can be restored by health personnel e.g. doctors, nurses C. Cultural practices ( ) always practices local cultural practices about heath matters ( ) sometimes practices local cultural practices about health matters ( ) does not practice any local cultural practices about health matters D. Community Involvement ( ) actively joins fiesta, religious procession, local cultural practices ( ) does not actively join C. Home and Environment Characteristics A. Housing a. Ownership: ( ) owned ( ) rented ( ) rent free b. Construction materials used: ( ) light ( ) mixed c. Number of rooms used for sleeping: ___________

( (

) least to own ) strong

d. Adequacy of space: ( ) adequate ( ) inadequate e. Lighting facility: ( ) electricity ( ) kerosene ( ) others, specify _______ f. Adequacy of lighting: ( ) adequate ( ) inadequate g. Ventilation: ( ) adequate ( ) inadequate h. General sanitary condition: ________________________________ B. Drinking Water Supply a. ownership : ( ) private/own household use ( ) public b. source: ( ) deep well ( ) local water district ( ) commercial c. potabilitry: ( ) yes ( ) no d. storage: ( ) none (direct from the faucet or pipe) ( ) large covered container with faucet ( ) large uncovered container without faucet ( ) others, specify: ______________________ C. Food Storage/Cooking Facilities a. Storage: ( ) refrigerator ( ) cabinet ( ) basket ( ) table ( ) covered ( ) uncovered b. Cooking facility: ( ) electric stove ( ) gas stove ( ) firewood/charcoal c. Sanitary condition: ___________________ D. Waste Disposal: a. Refuse and garbage: 1. Storage: ( ) container ( ) plastic bag ( ) none 2. Waste segregation: ( ) practiced ( ) not practiced 2.1 If practiced, method of disposal: ( ) hog-feeding ( ) open dumping ( ) burial in pit ( ) collected 2.2 Reason for practicing: ( ) environmentally friendly ( ) barangay ordinance which is strictly monitored ( ) use for business ( ) others, specify: _____________ 2.3 If not practices, method of disposal: ( ) hog feeding ( ) open dumping ( ) burial in pit ( ) open burning ( ) garbage collection ( ) composting ( ) others, specify: ______________ 2.4 Reason for not practicing: ( ) not aware of effects ( ) no time to do it ( ) long-time practice of family ( ) not a barangay ordinance/ not strictly monitored b. Toilet Facilities 1. Ownership: ( ) owned ( ) shared/public ( ) none 2. Type: ( ) ballot system ( ) open pit privy ( ) closed pit privy ( ) water-sealed ( ) others, specify: __________________ 3. Location from source of water: ( ) less than 20ft. ( ) 20ft beyond 4. Sanitary condition: ________________________ c. Drainage System: ( ) open drainage ( ) blind drainage ( ) none Condition: ( ) flowing ( ) stagnant

) composting

d. Practices/ measures done to control insects/vectors of diseases: ( ) fumigation ( ) insecticides ( ) setting traps ( ) cleaning the yard E. Presence of breeding sites: a. ( ) none ( ) with b. Practices/ measures done to control insects/vectors of diseases: ( ) fumigation ( ) insecticides ( ) setting traps ( ) cleaning the yard F. Kind of neighborhood: _________________ a. Social and health facilities available: __________________________ b. Communication and transportation facilities available: _______________________________

) none

) none

D. Health status of each Family Member 1. History of present/current or past significant illness of family members: _____________________ 2. Nutritional Assessment a. Anthropometric Data (age 0- 60 months and vulnerable member of family) Name Age in months/Age in years Wt. in Kg. Ht. in meters BMI Nutritional Status based Asia-Pacific Obesity Guidelines

Legend for nutritional status: U ( <18.5 ) underweight HW ( 18.6-22.9 ) healthy weight O ( >23 ) overweight Name of Child Age in months WC in cm. HC in cm. AR ( 23-24.9 ) At risk OI ( 25-29.9 ) Obese I OII ( >30 ) Obese II WHR (WC/HC) Interpretation MUAC Interpretation

b. dietary history A. Foods usually/most taken First choice: ( ) meat only ( Number of servings: ( )1 ( ) 2-3

) fish only (

) vegetable only

) mixed

) others, specify:____________________

) 4-5 and above

Second choice: ( ) meat only

) fish only

) vegetable only

) mixed

) others, specify:____________________

Number of servings: ( )1 ( ) 2-3 ( ) 4-5 and above Reason for choices: ( ) think its healthy ( ) own preference ( ) affordable ( ) personal belief/practice ( ) health condition Reason for not choosing other options: ( ) not healthy ( ) own preference ( ) not affordable ( ) personal belief/practice ( ) health condition B. From the above response, how frequent is the intake? ( ) everyday ( ) every 3 day ( ) once a week ( ) others, specify: __________________ C. How is food prepared for mealtime? ( ) prepared at home ( ) bought outside D. How often? ( ) everyday ( ) every 3 day ( ) once a week ( ) others, specify: __________________ E. If bought outside, is it from the: ( ) restaurant/fast food ( ) carinderia ( ) food cart ex. Fried chicken sa kanto, posit, provens F. Reason for the above option: ( ) convenience ( ) cheaper ( ) healthy ( ) variety of choices ( ) others, specify: _____________ G. Takes/ eat canned / preserved food. Ex. Lucky me, maling ( ) everyday ( ) every other day ( ) every week ( ) sometimes ( ) never H. Takes/ eat fried foods ( ) everyday ( ) every other day ( ) every week ( ) sometimes ( ) never I. Drinks carbonated beverages ( ) occasionally ( ) weekly ( ) everyday 2. Developmental Assessment (MMDST)

3. Risk factors assessment (lifestyle diseases) History/Presence of Non Communicable Disease in the Family (e.g. heart dse, Hpn, DM, cancer, Kidney Dse etc.) Name Age Gender NCD

History/Presence of Communicable Disease in the Family (e.g. chicken pox, measles, dengue, TB etc.) Name Age Gender NCD

Blood Pressure Record for ages 35 above Name Age Gender BP

4. Physical Assessment indicating presence of illness state, diagnosed/undiagnosed by medical practitioner (follow format of P.A in your Health Assessment subject) A. INDIVIDUAL TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS REMARKS

B. OB ASSESSMENT TOOL 5. Result of laboratory/diagnostic and other screening procedure supportive of assessment findings E. Values, Habits, Practices on Health Promotion, Maintenance and Disease Prevention a. Immunization record (0-12 months) put a check for all immunization received Name of Child Age in mos. Sex BCG DPT 1 DPT 2 DPT 3 Hepa B1 Hepa B 2 Hepa B3 OPV 1 OPV 2 OPV 3 Measles Complete Accdg to age Incomplete Accdg to age Fully Immunized Child

b. Beliefs Practices (per family) i. Person/nel mostly consulted in times of sickness/illness ( ) doctor ( ) nurse ( ) midwife ( ) hilot ( ) albularyo ( ) faith healer ii. Measures taken in times of sickness/illness ( ) consult a private health worker ( ) see a known community healer ( ) consult a rural health team ( ) self-medicate ( ) none iii. Medication/treatment taken in times of sickness/illness ( ) prescribed by doctor ( ) over the counter/self medication ( ) herbals ( c. Antenatal Registration Name AOG With Regular Not regular Prenatal Check-up Without Tetanus Toxoid Vaccination With Without

) elderly

) others, specify: _____________

d. Family Planning 1. Family Planning: ( ) acceptor

Reason: ( ( ) good for health of family ) religious belief ) bad for health of family ) religious belief ( ) permanent ( ( ( ( ) personal belief ) influence by others ) personal belief ) influence by others ( ) others, specify: ______

( ) non-acceptor Reason: ( ( 2. Methods used: ( ) natural ( ( ) others, specify: ______

) artificial

F. Community health programs 1. Awareness of health services offered by the BHC / RHU: ( ) aware ( ) unaware 2. What are the health services available in the barangay health center?