Sample Initial Database

Cavite State University

Don Severino De las Alas Campus, Indang, Cavite

College of Nursing
Initial Database for Community Health Nursing Practice
Date of Interview: ______________ Head of the Family: _______________________________ Barangay:_____________________ Address: ______________________________________________________________________

Demographic Data
Name of Members Position Age Sex Civil Status Ethnic Background Religion Education Occupation Income

Type of Family:

O nuclear

O Extended

O Others specify: _____________

Socio-Economic and Cultural Characteristics

Type of Occupation: O Blue Collar job O White Collar job O Self-employed O Others

Place of Occupation: ____________________________________________________________ Total Monthly Family Income: ____________________________________________________ Everyday Expenses: _____________________________________________________________ Who decides in the family? _______________________________________________________

Sample Initial Database

Environmental Factors
I. Housing Type of House: O concrete House ownership: O owned O mixed O light O makeshift O others, specify: ____________

O rented O rented free

Length of Residency: __________________ Residential Location: O subdivision _________ No. of rooms: ____________ No. of rooms for sleeping: ___________ Computation of TFA and over-crowdedness: ________________________________________ Power source: O with electricity O kerosene Ventilation: O satisfactory O fair O poor O w/o electricity O others specify: _________ O remote O squatters O others specify:

Computation for ventilation: ______________________________________________________

Water Supply Water Supply: O NAWASA O Artesian well O deep well Drinking water supply: O public O private O others specify: _____________

Potability: __________________

Distance from the house: ________________________________________ Ownership: O owned O public O large, covered, w/ faucet

Drinking storage:

O none O large, covered, w/o faucet

O others, specify: _____________________ Kitchen Food Storage: O ice box O cooler O refrigerator O others specify: _____________ O charcoal O others specify: _________

Cooking facility: O gas stove

O electric stove

Sanitary condition: ____________________________ Drainage facility: O open drainage O blind drainage O none

Sample Initial Database

Waste Disposal a. Refuse and garbage Method of disposal: O open burning O open dumping O burial in pit O composting O others specify: __________ Container: O covered O open O none O pit privy O others specify: ________ O garbage collection O animal feeding

b. Toilet facility:

O water sealed O septic tank

Distance from the house: ____________________________ Sanitary condition: _________________________________ Domestic animals: O dogs O cats O birds/fowls O others specify: _____________

No. of domestic animals: ____________________ Where the animals are kept? ________________________ General sanitary condition: II. Neighborhood Kind of Neighborhood: O congested O not congested O troublesome O peaceful O satisfactory O fair O poor

O others specify: ______________ During the night, is there any trouble in your community? ________ If yes, what is the usual cause? _________________________________ III. Social and Recreational Facilities A. Recreational facilities: O malls O movie houses O parks O courts O others specify: ______ How often do you go out to do recreations? _______________________ B. Social facilities: O court O Barangay Hall O others specify: ________________ Are joining any social functions? __________________ IV. Communication and Transportation

Sample Initial Database

Communication facility: O telephone O cell/mobile phone O snail mail O email O others specify: _______________ Forms of Transportation: O owned vehicle specify: ___________ If commute, specify the type of transportation: O jeep O tricycle O bus O bicycle/pedicabs O by foot O commute

O others specify: ____________

Health and Medical History

Past Illness Name of the Family member Age Disease Medical attendance Medications and treatments

Present Illness

Name of the Family member

Age

Disease

Medical attendance

Medications and treatments

Family Medical History Genetic disposition (hereditary diseases) Mother Side O Diabetes Father Side O Diabetes O Hypertension O Cancer O Asthma O Others specify: ______ O Hypertension O Cancer O Asthma O Others specify: ______

Immunization Status

Sample Initial Database

From 0 5 yrs old Name of the Family member Age Vaccines Remarks

BCG

DPT

OPV

HepaB

Measles

others

Remarks (choices): complete incomplete

Hospitalization Name of the family member Age Reason Length of Confinement Operation

Sources of Medical Care O Health Centers O hospitals O clinics O private physician O faith healers

O others specify: _______ How far is it from your house from the source of medical care? __________________________ Where do you get medicines: O OTC O prescribed by doctors O self medication O herbal medicines

O others, specify: __________

Supplements Vitamins Intake

Sample Initial Database

Are you taking vitamins? O yes O no What supplements are you taking? Specify: ___________ Name of the family member Vitamins and supplement

Physical Activities Do you exercise? O yes O no

How often do you exercise: O once a week O twice a week O three times a week O everyday How long do you exercise: O 15min What kind of exercise: O jogging O walking O swimming O cycling O others specify: ______ O 30min O 1hr O 2hr

O weight lifting O stretching O bars O aerobics O others specify: _________ Nutrition How often you eat in a day? _________ How many cups of rice do you eat in a day? __________ Food preference of the family: O rice O pork O bread O instant noodles O chicken O fruit O beef O seafood/fish O milk O canned goods

O vegetables O coffee

O soft drinks O water O fruit/vegetable juices

O others specify: __________ Nutritional Assessment From 0 5 yrs of age

Sample Initial Database

Name of the Family member

Age Gender Height Weight Body Mass Index

Eating habits and practices

Remarks

Remarks: Normal Undernourished Over-nourished

Family Planning Name of the Family member Age Methods of Contraception Recipient

Methods of contraception: Pills Injectables Condom IUD Natural family planning Ligation Vasectomy

Others (specify)________ Births in the family in year 2008 2009? __________________________________ Name of Mother Date Para

Deaths in the family in year 2008 2009? _________________________________ Name Age Cause of death Date

Diseases in the family in year 2008 -2009? _________________________________ Name Diseases Date of Diagnosis Medications & Treatments

Sample Initial Database

Health beliefs system: __________________________________________________

Priorities: What are the familys top priorities? 1. 2. 3. 4. 5.