SAINT LOUIS UNIVERSITY

School of Nursing
FAMILY NURSING ASSESSMENT TOOL

Color highlight legend

Green manifestations / cues of an acceptable
standard/normal
Yellow incomplete data that student has to
further complete
Family: Shilan, La Trinidad, Benguet
Red manifestations/cues of a possibly
(House #, Purok or Zone, Street #, Barangay, Municipality, Province)
abnormal condition

Address of
FAMILY NAME:
C
INFORMANT:
Malou C
NAME OF HEALTH CENTER: _________________________________
A. FAMILY STRUCTURE, CHARACTERISTICS
FAMILY
RELATIONSHIP TO
MEMBERS
THEHEAD (head, wife
(include only
of head, son, daughter,
those living in the
mother/father/in-law,
household. Start
niece/nephew, cousin,
from the head
househelper, etc)
then immediate
members then
non-members
living with family
as last)
Freddie
Head of family
Malou

Wife of head

Eloisa
Justin

Daughter
Son

AND DYNAMICS/RELATIONAL PATTERNS

POSITION/ORDER IN THE
BIRTHDATE
FAMILY / OTHER ROLES
(month & year)
(Father & breadwinner,
mother and store keeper, 1st
child & cleaner, 2nd child and
cook, etc.)

Father
and
main
breadwinner
Mother,
store
keeper;
attends to all household
tasks
First child
Second child

TYPE OF FAMILY:
FAMILY
communication/interaction patterns between/
caring/helping, listening, ability to handle conflict, change, anticipated and unexpected events;
According to structure & composition: TRADITIONAL NUCLEAR

SURVEYED / DATA GATHERED BY: Adelaidadela Cruz and Ma. Ana Juan
DATE SURVEYED / GATHERED: October 3, 2016

AGE
(should be
exact in
years and
in months)

39 yrs old

GENDER

MARITAL
STATUS

Shilan, La Trinidad
Arabia)
Shilan, La Trinidad

7 yrs old
4 yrs old

F
M

DYNAMICS/COMMUNICATION

PLACE OF RESIDENCE / WORK /

STUDY (including nonemancipated working or
studying family members
whether living with family or
elsewhere)

Single
Single

Shilan, La Trinidad
Shilan, La Trinidad

(Saudi

DOMINANT DECISION
MAKERS IN MATTERS OF:
(Please check appropriate
column below)
HEALTH&
MONEY &
CARE
EXPENSES
TENDING

X
X

X
X

PATTERNS/INTERACTIONAL
PROCESSES:
(describe
the
characteristic
among subsystems evidences of love, openness/warmth,

evidences of presence or absence of any obvious or readily observable conflict/s between members, etc.)

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SAINT LOUIS UNIVERSITY

School of Nursing
According
According

to
to

family head and decision making: EGALITARIAN

Spousesubsystem: HUSBAND GOES HOME EVERY YEAR; WRITES LETTER
roles/bread-earning :DUAL
Parent-child
_______________________________________________________________________________________________________
Sibling-sibling subsystem: _____________________________________________________________________________________________________

B. SOCIO-ECONOMIC AND CULTURAL CHARACTERISTICS

FAMILY MEMBERS
HIGHEST EDUCATIONAL
RELIGIOUS AFFILIATION
RELIGIOUS SECT
WHAT RELIGIOUS SECT
ATTAINMENT (last level
WHERE BAPTIZED
IS THE MEMBER ACTIVE
completed at the time of
survey & none)
Freddie
College graduate (bank
teller)
Malou
Eloisa
Justine

ETHNIC BACKGROUND

OCCUPATION

Ibaloi

Bank teller

Ibaloi
Ibaloi
Ibaloi

Store keeper

INCOME(gathering this
data requires nonleading & nonembarassing questions)

subsystem:

OTHER SOURCES OF
INCOME

P60T remittance
Sari-sari store
Not applicable
Not applicable

BUDGET AND ACTUAL EXPENSES (Please specify in the table if the budget and expenses is daily, weekly or monthly-based. Questions to elicit this set of data should be very discreet, non-direct and nonembarassing):
BASIC NECESSITIES
BUDGET
ACTUAL EXPENSES
CONCLUSION: ADEQUACY TO MEET BASIC NECESSITIES USING THE TOTAL INCOME, BUDGET AND
ACTUAL EXPENSES AS BASIS
Food and water
Adequate (income=budget and actual expenses); inadequate (actual expenses exceeds budget
Shelter (home maintenance/repairs, rent)
and income); more than adequate (income exceeds actual expenses)
Clothing
Education
Health
Electricity, electronics, communication and
other services
Others (car repair/maintenance, gasoline, etc.)
TOTAL
SIGNIFICANT OTHERS OF THE FAMILY

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SAINT LOUIS UNIVERSITY

School of Nursing
NAME/S OF
MEMBERS

SIGNIFICANT

PLACE OF RESIDENCE

ROLES PLAYED IN THE FAMILY

FAMILY TRADITIONS, EVENTS OR PRACTICES THAT AFFECT MEMBERS HEALTH OR FAMILY FUNCTIONING (please describe):

hypertension.

SUPPORT THAT THEY PROVIDE

Familys belief that eating carabao meat will cause abortion and

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