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INITIAL DATA BASE Form For Family 1

This document contains a community health nursing assessment of a family. It collects data on the family structure, relationships, activities, socioeconomic factors, environment, health history, and preventive practices. Three potential health problems or promotive practices are identified for the family. Each is then scaled according to nature, modifiability, preventive potential, and salience to prioritize which should be addressed.

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Reignallienn Inocencio Martin
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62 views5 pages

INITIAL DATA BASE Form For Family 1

This document contains a community health nursing assessment of a family. It collects data on the family structure, relationships, activities, socioeconomic factors, environment, health history, and preventive practices. Three potential health problems or promotive practices are identified for the family. Each is then scaled according to nature, modifiability, preventive potential, and salience to prioritize which should be addressed.

Uploaded by

Reignallienn Inocencio Martin
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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COMMUNITY HEALTH NURSING RLE

PART A. INITIAL DATA BASE


I. CHARACTERS:
A. What is the type of family structure?
Nuclear Single - Parent
Extended Others (specify)
B. What is the type of family based on authority?
Patriarchal
Matriarchal
C. Who makes decisions regarding health care?
D. What is the present family relationship?
with conflicts between members
without conflicts between family members
E. Activities of daily living:
1. Sleeping pattern:
Retiring/getting up hours
Nap during the day
Do members sleep together
2. Eating pattern
How many meals each day?
Who appears overweight?
Who appears underweight?
3. Leisure time activities
How does each member spend leisure hours?
Is it appropriate for the sex and age group?
What is the effect on the family?
Any joint activity for leisure?

II. FAMILY INFORMATION


Head of the family:
Address:
Members of the household:

NAME RELATIONSHIP AGE EDUCATIONAL ATTAINMENT

/avg 1
III. SOCIO-ECONOMIC AND CULTURAL FACTORS
A. Income

NAME OCCUPATION PLACE INCOME /


MONTH

1. Does the working family member meet the basic necessities?


Yes No
2. Who makes decisions regarding money matters?
3. Religious affiliation:
4. What roles does the family play in the community?

IV. ENVIRONMENTAL FACTORS


A. Housing
1. Ownership
Owned Rented Rent-Free Others (specify)
2. Construction materials used
Light Mixed Strong
3. Living space
Adequate Inadequate
4. Sleeping arrangement:
5. Adequacy in furniture
Adequate Inadequate
6. Water source
Private Public
7. Food storage
Refrigerator Jars/container Others (specify)
8. Cooking facility
Electric stove Firewood Others (specify)
Gas Stove Kerosene
9. Drainage facility
Open drainage Blind drainage None
10. Toilet facilities/type
Flushed Overhung latrine
Water-sealed latrine Bored-hole latrine
Pail system Others (specify)
11. Sanitary condition
Fair Good Poor
Provide brief description:

12. Neighborhood
Congested Slum Other
13. Availability of Health Care Facility
/avg 2
Describe briefly:
14. Garbage disposal
Dumped at street corner Picked up by garbage collector
Buried Burned then buried Others(specify)

V. HEALTH MEDICAL HISTORY


NAME PAST ILLNESS DIAGNOSED / ILLNESS STATE HEALTH ACTION
UNDIAGNOSED TAKEN

VI. VALUE PLACED ON PREVENTION OF DISEASE

Vaccinations

NAME AGE COMPLETE INCOMPLETE

Other preventive practices employed by the family:


Sources of Health Care:
Health Center Government Hospital
Private Hospital Others (specify)

/avg 3
PART B.

DETERMINE AT LEAST 3 FAMILY HEALTH PROBLEMS. IF NONE, DETERMINE THE FAMILY’S PROMOTIVE OR PREVENTIVE
PRACTICES.

FAMILY HEALTH PROBLEMS. TYPOLOGY OF HEALTH PROBLEM


(WELLNESS STATE , HEALTH DEFICIT,HEALTH THREAT,
(IF NONE, FAMILY’S PROMOTIVE OR FORESEEABLE CRISIS)
PREVENTIVEPRACTICES.)

PART C.

DO THE SCALING OF THE 3 IDENTIFIED HEALTH PROBLEMS OR PROMOTIVE PRACTICES OF THE FAMILY.

HEALTH PROBLEM 1:

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

NATURE OF THE PROBLEM

MODIFIABILITY OF THE
PROBLEM

PREVENTIVE POTENTIAL

SALIENCE

TOTAL

HEALTH PROBLEM 2:

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

NATURE OF THE PROBLEM

MODIFIABILITY OF THE
PROBLEM

PREVENTIVE POTENTIAL

SALIENCE

TOTAL
/avg 4
HEALTH PROBLEM 3:

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

NATURE OF THE PROBLEM

MODIFIABILITY OF THE
PROBLEM

PREVENTIVE POTENTIAL

SALIENCE

TOTAL

Surveyed by _________________________
Date ______________________________

/avg 5

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