SAINT LOUIS UNIVERSITY

School of Nursing

RELATIONSHIP OF THE FAMILY TO THE LARGER COMMUNITY: Connect the family to the different aspects of the community using the
legend below in order to determine the familys ability to maintain a reciprocal relationship with the community and to determine if the
family is a closed or open system.
Strong connection
Church
Tenuous connection

Stressful connection
Etc
Reciprocal direction of
energy & resources

M F No connection /
participation (no line)
RHU/Hos Etc
p

School
neighbor

C. HOME AND ENVIRONMENT (Use OBSERVATION only as method of data gathering if at all possible. Supply data with words, , X or NA or not
applicable. Do not leave any blank as this will mean not assessed).
1) HOUSING Owned: Rented:
Total # of rooms of house: 3 Approx size of each sleeping room (sq m): ______ # of people occupying each room:
Lighting: Electricity: Kerosene lamp: _____ Rechargeable battery: __x____ Candle: ______
Others, specify
Ventilation: Specify how many windows does each room have: ___2____
Type of materials used:
Light (bamboo, nipa, etc): Mixed (combination of wood, GI, cement): Permanent/strong (cement):
Others (please specify):
Presence of breeding/resting places of vectors (roaches, flies, mosquitoes, rats, etc.): None observed: ___x____
Present: ______ Location (pls specify kitchen, garbage inside the kitchen, etc.): _kitchen and rooms__________
Kitchen: Generally clean surroundings: __x__ Generally unclean: ____
Pots and pans washed and kept in cupboards __x__ Pots, pans, plates scattered and unclean ____
No flies/cockroaches/rats observed __x__ Flies/cockroaches/rats visible ____
Food storage (check as many as applicable)
Refrigerator: x
Food : closed _x___ open: __x__
Pot/food keepers/plastic containers: with cover __ without cover ____
None because all food is consumed every meal __ Others (specify) __none___________________________
Presence of accident hazards (check as many as applicable)
Sharps unkempt: _x_
Medicine cabinet: Present: __x__ Absent: ____
With lock __x__ Where are medicines kept: _in the table___
Without lock ___
Where are poisons kept: __in a garden tool and pesticide w/o lock located inside the house______________________________
Cooking facility: Gas range Gas stove __x__ Electric stove __x__
If gas stove or gas range: With safety device _x___ Without __x__
Dirty kitchen__ __
With clean surroundings __x__ With piled garbage/combustible debris near it ____

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 SAINT LOUIS UNIVERSITY
School of Nursing

Burning of food: Never occurred __x__ Seldom occurs ____ Commonly occurs
__x__
Checking of stove before family members leave the house:
Not a practice _x___ Only a few members do this __x__ Consciously done by all members __x__
Electrical wiring checked annually: Yes ____ No ____
Attitude of members leaving sockets with plugs still connected: Yes __x__ No ____
Presence of stairs in the home: Yes ____ None __x__
If yes: with rails ____ None but necessary __x__ Not necessary _x_
Members walking barefoot:
When entering CR/bathroom: Yes _x_ No ____
When going outside the house: Yes _x_ No ____
Slippery floors: Present ____ None __x__
Domestic animals that bite: Present __x__ None ____
Highway in close proximity to the house: Yes _x___ No ____
Others (specify): __none____________________________________________________________________________________
Water supply:
Source: Level I (protected spring, deep well) ____ Level II _x__ Level III __x__ Others (specify) __x___
Ownership: Family-owned __x__ Shared with other families ____ How many families __whole___
Storage of drinking water (check as many as applicable):
Earthen jar: with cover ____ without cover __x__
Bottles / plastics: with cover ____ without cover __x__
Water dispenser: __x__ Others (specify): _________none__________ None __x__
Storage of water used for cooking:
Water tank: with cover __x__ without cover __x__
Drums: Plastic: ____ Tin drums ___
Others (specify) __none____________________________________________________________________________
Potability: Boiled _x___ Tested: Yes _x___ Not tested ____
If tested: When last tested ___x___________________ Who did the test _____x____
Results of test: _____________x_____________________________________________________________________
Domestic animals
Type of animal Number Check appropriate column
With cage Stray
Dog None
Fowl (specify) 15
Cat None
Pig None
Others (specify) None
Toilet facility:
Type: Level I ____ Level II _x___ Level III __x__
If open pit privy, specify location and distance from the kitchen
Ownership: Family-owned Public
Shared with other families __x__ How many families __x__
Sanitary condition: No smell _x__ Foul-smelling ___ With flies ____ No flies __x__
Garbage or refuse disposal:
Type: Landfill ____ Composting __x__ Burying __x__ Burning __x__
Open dumping ____ Location and distance from the house ____10 meters___________________________
Garbage collection: none Schedule of collection: none
Segregation of waste: Practiced by family Not practiced
Sanitary condition: No flies _x___ No smell _x___ With flies ____ With smell ____
Drainage system: Type: Closed/blind x Open None (directly to the ground):
Drainage continuously flow With stagnation of drainage:
Sanitary condition: Frequented by vectors ____ Not frequented by vectors ____
2) KIND OF NEIGHBORHOOD
Rural Rurban x Urban x Slum area x
Distance of one house to another (approx in meters) Population density: __not taken____
Conclusion: Congested Not congested

3) SOCIAL/RECREATIONAL AND GOVERNMENT FACILITIES

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 SAINT LOUIS UNIVERSITY
School of Nursing

FACILITY CHECK IF DISTANCE FROM HOUSE FAMILY AWARENESS & UTILIZATION

PRESENT (approx in meters or kms) Check if family is Check if family
aware utilizes
Social / government facilities 4-km
Day Care / Nursery 1-2km
Elementary school 1-2 km
High school X
Vocational school X
College X
DSWD X
DENR X
Others (specify)
Recreational facilities
Sports center
Others (specify)
Non-government agencies servicing the comty

Peoples organization present in the community

4) HEALTH FACILITIES AND MANPOWER AVAILABLE

HEALTH FACILITY DISTANCE FROM TYPE & # OF MANPOWER FAMILY AWARENESS & UTILIZATION
HOUSE (approx in m AVAILABLE Check if family is Check if family
or in kms) aware utilizes
Barangay Health Station 2-6 km RHM

Rural Health Unit 2-6 km

Emergency / District Hospital n/a

Others (specify) None None None None

5) COMMUNICATION FACILITIES
Phones: mobile land phone __X__ radio ____ TV ____ computer X
Letter _X___ word of mouth ____ others (specify) ___________________________________________

6) TRANSPORTATION FACILITIES ON A 24-HOUR BASIS: None ____ Only hitch rides __

Private car __x__ Taxi PUJ Van ____ Tricycle __x__ Passenger bus __x__

D. HEALTH STATUS OF EACH FAMILY MEMBER

Obstetrical history
NAME OF CHILD AGE OF FREQUENCY OF PLACE OF DELIVERY TYPE OF REMARKS
(Listed by order of MOTHER PRENATAL CHECK Attendant at Just check if DELIVERY (NSVD, (Specify if alive or
arrangement in the family) WITH THIS UPS (eg: 1x every home hospital delivery LCCS, Assisted dead on
PREGNANCY mo, 3x during delivery specify assessment. If
whole pregnancy, if with difficulty dead, specify
etc) or none) reason)
Angelo 1visit every month Husband NSVD alive
Jeric 1visit every month Husband NSVD alive
Michelle 1visit every month Husband NSVD alive
Melody 1visit every month Husband NSVD alive
Robin 1visit every month Husband NSVD alive
Family developmental stage:
Expected tasks:
Developmental assessment of infants, toddlers and preschoolers through the MMDST (separate assessment tool)
Nutritional assessment of vulnerable family members (infants, children, pregnant, post-partum mothers, sick members & members with
clinical manifestations of thinness or undernourished)
VULNERABLE FAMILY WEIGHT HEIGHT MID-UPPER ARM FOOD PREFERENCES EATING/FEEDING
MEMBER CIRCUMFERENCE HABITS/PRACTICES
(for children only)
Rosela 200 kg 54 N/a Rice canned goods Eat lunch irregularly

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 SAINT LOUIS UNIVERSITY
School of Nursing

Dietary history indicating quality and quantity of food intake per day:
CONTENT & AMOUNT BREAKFAST LUNCH SUPPER
Usual content of food
Amount of food intake
(average)
Risk assessment measures for obese members of the family
MEASURE / INDICATOR EXPECTED NORMAL FINDINGS ACTUAL FINDINGS
OBESE FAM MEMBER FINDINGS
Body mass index (BMI = wt in kgs / ht in m2) 18.6 to 22.9
Waist circumference <90 cm for men; <80 cm for women
Waist-hip ratio (WHR = waist circumference in Less than 1 cm in men; less than .85
cm/ hip circumference in cm cm in women
Assessment of common risk factors leading to non-communicable diseases (check as many as applicable)
RISK FACTOR CHECK THOSE NON-COMMUNICABLE DISEASES WHEREBY FAMILY MEMBER/S ARE PREDISPOSED OF (pls
PRACTICED IN THE check appropriate column)
FAMILY CVD DM CANCER RESP CONDITION
Alcohol intake
Blood glucose level, elevated
Blood lipids/cholesterol, elevated
Blood pressure, elevated
Family history of cancer, DM, HPN, etc
Inadequate fiber intake
Nutrition/diet, poor
Obesity
Physical inactivity
Sedentary life style
Smoking cigarette or tobacco
Assessment of risk factors leading to common communicable diseases (check as many as applicable)
Possible risk factors Check as COMMUNICABLE DISEASE FOR WHICH FAMILY ARE PREDISPOSED OF
many risk (check as many as applicable)
factors PTB Other respiratory Dengue & other Diarrheal
present diseases mosquito-borne dis disease
Exposure to a suspect/registered TB case
Exposure to a respiratory-related CD
Lives in a known dengue-infected area
Does not regularly practice the following habits:
Changing H2O/scrubbing sides of flower vases
Not cleaning surroundings
Non-disposal or rubber tires, empty bottles & cans
Not keeping water containers covered
Too many hanging clothes inside the house
Poor environmental sanitation
Non-potable water supply
Unsanitary food sources, preparation and serving
Fond of eating street foods
Malnourished
Focused assessment results of vulnerable family members indicating presence of illness states
Vulnerable Chief complaint Family beliefs as to causes Remedies done by family
member Medical consult to Home remedies Remarks
whom/where initiated
Jeric Cough and colds Cold weather Home

Michelle Cough and colds Cold weather Home

Melody Cough and colds Cold weather Home

Medical and nursing history indicating current or past significant illnesses or beliefs and practices conducive to health and illness
Family member Past illness Beliefs as to causes Remedies done by family
Home Hosp / consult Remarks
None

None

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 SAINT LOUIS UNIVERSITY
School of Nursing

Results of laboratory/diagnostic or screening procedures undergone by vulnerable family members

Family member Laboratory/diagnostic/screening procedure
Procedure done Expected normal findings Actual findings
none
none
none
none

E. VALUES, HABITS, PRACTICES ON HEALTH PROMOTION, MAINTENANCE AND DISEASE PREVENTION

BELIEFS AND PRACTICES OF PROMOTIVE & PREVENTIVE HEALTH SERVICES
Immunization status of family members, especially children 0-8 years old and mothers of reproductive age (14-49 years old)
FAMILY MEMBERS BCG HBV OPV DPT AMV TT
1 2 3 1 2 3 1 2 3 1 2 3 4 5
Lito x x x x x x x x X x x x x x x x
Lucia x x x x x x x x X x x
Rosela x x x x x
Jeric x x x x x
Michelle x x x x x
Melody x x x x x
Reasons for submitting self or children for immunization: _________________________________________________________
________________________________________________________________________________________________________________
Regular check ups
Family member Age Promotive / preventive services
Never goes Goes only Goes for Does Annual Dental Annua Stool Testic
for check up for check annual month PAPs exam = 1- l eye guiac ular
even if ill up if ill PA ly SBE smear 2x a year exam test exam
Lito 50 x x X x x X x x
Lucia 49 x x X x x X x x
Rosela 25 x x X x x X x x
Jeric 13 x x X x x X x x
Michelle 12 x x X x x X x x
Practice of family planning methods (applicable for married couples of reproductive age or MCRA = 14-49 years old)
FP acceptor: x FP user: x FP Non-acceptor ____
Method accepted: x Method being used: none
Reason for acceptance and use: ______________________________________________________________________________
Reason for non-acceptance / non-use:_natural method_________
Misconceptions heard about the use of FP: _____none___________________________________________________________
________________________________________________________________________________________________________
VALUES, HABITS AND PRACTICE OF OTHER HEALTH LIFE STYLES
Exercise, rest and sleep
Family Rest and sleep Exercise Relaxation Stress
members # of hours Interrupted Naps Naps Nature of Frequ # of activities management
per night or present absent exercise ency minutes activities
continuous per per employed
week exercise
Lito 7 continous Brisk walk 7 30 mins Sleeping, Sleeping,
Lucia 7 continous 7 30 mins watching TV watching TV
Rosela 8 continous 7 30 mins
Jeric 8 continous 7 30 mins

Beliefs and practices about nutrition during menstruation, pregnancy, childbirth, illness, feeding babies, etc.
Menstruation: ___none_____________________________________________________________________________________
Pregnancy: ___dont take a bath after delivery__________________________________________________________________
Childbirth: ____none_______________________________________________________________________________________
Feeding babies: ___none____________________________________________________________________________________
Illness: __________________________________________________________________________________________________
Others: _fat babies are healthy babies_________________________________________________________________________
- End of questionnaire
Prepared by: Core Group on NCP and FNCP Formats, School of Nursing, October 2010)

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