INITIAL DATA BASE

Family Surname :_________________ Name of Family Head:_______________

House No.:_____Street:_______________________ Purok Number:__________

Purok Name: ______________Barangay:__________ Municipality:___________

Source of Information:_________________________ Relation:______________

Data gathered by:_____________________________ Date : _______________

A. Household members:

No. Family Sex age Civil Relation Religion Educational Occupation

Members status to Head Attainment
 B. Family Characteristics:
Type of family structure:

( ) Nuclear family ( ) Dyad family ( ) Compound family

( ) Extended ( ) Blended family ( ) Cohabiting family

( ) Single parent family

Family Members living outside the household

Name Age Relationship Location Occupation/ Frequenc Means of

to head of y of communication
Work
Member contacts

Family Mobility:

Length of time of current address:______________

Address of previous residences : ________________________________________

Frequency of geographic moves: ________________________________________

Family Dynamics :

Emotional bonding of Family members __________________________________

Distribution of authority and power ____________________________________

How members communicate __________________________________________

Dominant Family Members in terms of decision making

( ) Husband ( ) Adult children

( ) Wife ( ) Others, specify:_________________________

How problems are solved _____________________________________________

How conflict is handled _______________________________________________

Division of labor_____________________________________________________

C. Socio-economic and cultural characteristics:

Family social integration:
Language(s) or dialects (s) spoken
( ) visayan/ Cebuano ( ) tagalog
( ) english ( ) others specify,________________________

Literacy ( ablility to read or write in language (s)

( ) Yes
( ) No

Degree of social network with friends, neighbors and other

relatives________________________________________________________

Networks with religious organizations ( name of religious organizations, the

family members are involves ______________________________________
Networks with social organizations ( Name of organizations the family is
involved) ______________________________________________________

Educational experiences _________________________________________

Work experiences ______________________________________________

Adequacy of financial resources :
Monthly family income source:
( ) Husband : __________________
( ) Wife :___________________
( ) Others, specify :___________________

Monthly family income : ( Total ) Please check bracket

( ) Below 5,000
( ) 6,000- 10,000
( ) 11,000 – 15,000
( ) 16,000 – 20,000
( ) 21,000 – 30,000
( ) 30,000 – 40, 000
( ) 40, 000 – 50,000
( ) above 50,000

Felt Family needs:

( Identify and rank according to priority)
1.

2.

3.

4.

5.

Leisure time interest: ( Name some leisure time activities) ______________

 ______________________________________________________________

D. Cultural influences :values attitudes, and beliefs about:

Spirituality : ____________________________________________________
Rituals : ( Holidays and celebrations ) _______________________________
Dietary habits : _________________________________________________
Health : _____________________________________________________
Folk diseases : ________________________________________________
Traditional healers: ____________________________________________

E. Family and environment :

1. Home
a. Ownership
( ) owned ( ) rented ( ) rent-free
b. Construction materials used
( ) light ( ) mixed ( ) strong
c. Number of rooms used for sleeping: ___________
d. Lighting facilities
( ) electricity ( ) kerosene ( ) others, specify:
______________
e. General sanitary condition_________________________________
2. Drinking and water supply:
a. Source
( ) level 1 – ( point source)
( ) shallow or deep well
( ) Improved dug well
( ) developed spring
( ) rain tank
( ) level 2 – communal faucet
( ) waterworks system
( ) water refilling station
b. Distance from the house _______________
c. Storage :
 ( ) None ( direct from the faucet)
( ) large covered container with faucet ( water dispenser, jars,etc)
( ) Large uncovered container without faucet
( ) others, specify

3. Kitchen
a. Cooking facility used:
( ) electric stove
( ) gas stove
( ) firewood/charcoal
( )others specify: __________________

b. Food storage:
( ) covered
( ) uncovered
( ) refrigerator ( container with cover )
( container without cover)
c. Sanitary condition : ___________________
d. Drainage facility of kitchen :
( ) open drainage
( ) blind drainage
( ) none

4. Waste disposal:
a. Garbage container
( ) covered ( ) open ( ) none
b. Method of disposal:
( ) hog feeding ( ) open burning
( open dumping ( ) garbage collection
( ) burying in pit ( ) others, specify
( ) composting
 c. Excreta disposal:
( ) tanked flush toilets ( connected to septic tanks and /or sewerage

system)

( ) Pour – flushed latrine

( ) ventilated – improved pit latrine ( VIP)
( ) overhung latrine
( ) antipolo toilet
( ) pit latrine
( ) box- and- can privy
( ) shared
( ) none
d. Distance from the house : _________
e. Sanitary condition : ( describe briefly the state of cleanliness)
__________________________________________________

5. Domestic animals / common household pets:

Kind Number Where kept

6. Pest and vermin control:

a. Presence of breeding sites of insects, rodents, etc
( ) yes, specifically: _________________________
( ) No

7. Presence of accident hazards:

 ( ) yes ( ) No
If yes, specify:
( ) broken parts of the house ( ) slippery pathways
( ) sharp objects ( unkept)
( ) medicine ( unkept)
( ) broken glasses
( ) unkept animals
F. Family Neighbourhood
a. Location
( ) urban
( ) rural
( ) subdivision
( ) slum area

b. Type of neighbourhood
( ) residential
( ) semi-commercial

c. Safety
( ) traffic patterns
( ) lighting
( ) security ( police or pvt.)
( ) pedestrian lanes
( ) walking pathways

d. Population density ( crowding)

( ) congested
( ) non- congested

e. Sources of pollution
( ) air
( ) water
( ) soil
 ( ) noise

f. Social and health facilities available

( ) BHS ( ) Chapel
( ) RHU ( ) senior citizens’ building/hall
( ) Pvt. Clinics/hospital
( ) barangay hall
( ) basketball court
( ) purok kiosk/ centers

g. Communication facilities of the family:

( ) Cellphones
( ) Landline telephones
( ) Internet

h. Transportation facilities :
( ) Public Utility vehicle/Jeepneys ( PUV/ PUJ)
( ) Owned pvt. Cars
( ) owned motorcycles
( ) rented vehicles

G. Family Health and health behaviour

a. Activities of daily living ( how family spends a typical day)
_______________________________________________

b. Health history :
1. Pregnancy –
________________________________________________
________________________________________________

2. Illness - __________________________________________
_________________________________________________
 3. Death within the past 5 years :
( ) Yes ( ) None
If yes, indicate cause of death: ________________________

4. Health attendance: ( How often)

( ) every month ( ) once a year
( ) as the need arises ( ) never
( ) others, specify: ______________________

c. Self care activities: ( Name family’s related activities)

Health promotion :

Disease prevention :

d. Risks factor assessment for specific lifestyle diseases:

( ) hypertension ( ) obesity
( ) physical inactivity ( ) diabetes mellitus
( ) sedentary lifestyle ( ) inadequate fiber intake
( ) cigarette/ tobacco smoking ( ) stress
( ) elevated lipids/ cholesterol ( ) poor diet
( ) alcohol drinking ( ) other substance abuse
( )others, specify: ______________________________________

e. Present Health status:

Father / family head : ___________________________________
Vital signs:
T - ___________ BP- ___________ HR - ________ RR-___________
Physical complaints : ______________________________________
 Mother /Wife : ____________________________________________

Vital signs :

T - __________ BP-___________HR- _________ RR- ___________

Physical complaints: _______________________________________

________________________________________________________

Other Family members:____________________________________

Vital signs:

T- _________ BP -_________ HR - _________ RR- _____________

Physical complaints: ______________________________________

_______________________________________________________

f. Common Illnesses encountered and management applied :

Age Illness Management

0–1

1 -3

3–6

6–7

7 – 12

13 – 18

19 – 25
26 – 35

36 – 45

46 – 50

51 - 55

56 – 60

60 and
up

g. Health care resources

a. Where do you consult for health related problems?
( ) manghihilot ( ) RHU’s ( MHO, PHN, PHM)
( ) Pvt. Clinics/ Doctors ( ) alternative Treatment clinics
( ) BHW’s ( )others, specify: _______________
b. For problems other than health, whom do you consult?
( ) family members ( ) relatives
( ) friends ( ) Barangay officials
( ) Priest ( ) Health workers
( ) others, specify:__________________________

c. Immunization status of children :

1. Are the children immunized ?
( ) Yes ( ) No ( ) Incomplete
Why: __________ Why: __________
 2. If yes, check immunization if they had :
( ) BCG ( ) Hep B Vaccine
( ) OPV ( ) AMV
( ) Pentavalent Vaccine ( ) MMR
( DPT, HepB, Hib ) ( ) Others, specify:______________

d. Adequacy of :
1. Rest and sleep
( ) Yes ( ) No
If No, Why? : __________________________
2. Exercise/ Physical activity
( ) Yes ( ) No
If No, Why? ___________________________

3.Stress management activity/ relaxation

( ) Yes ( ) No
If No, why? ___________________________
If yes, how often?
( ) daily
( ) three times a week
( ) once a week
( ) once a month
( ) never
( ) Others, specify: ______________________