UNIVERSITY OF CEBU – BANILAD

COLLEGE OF NURSING

INITIAL DATA BASE FOR FAMILY NURSING PRACTICE

Family Surname : _______________________________
Barangay : _______________________________ Municipality/ City : _______________________________
Source (s) of Information : _______________________________ Contact No. : _______________________________
Data Gathering : _______________________________ Date : _______________________________
Type of Family : _______________________________

A. HOUSEHOLD MEMBERS (all who resides in the family home)

RELATIONSHIP TO HIGHEST
NAME GENDER AGE HEAD OF EDUCATIONAL OCCUPATION HEALTH PROBLEMS
HOUSEHOLD ATTAINMENT

Note : Insert genogram,family tree ( indicating health problems of individual members)

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 GENOGRAM OF FILOMENO FAMILY

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 FAMILY HEALTH TREE OF __________________ FAMILY
(NAME)

1. Causes of death of deceased family members

______________________ _________________________
______________________ _________________________
______________________ _________________________
______________________ _________________________
2. Genetically linked diseases:
 Heart Disease
 Cancer
 Diabetes
 Hypertension
 Allergies
 Asthma
 Mental retardation
3. Environmental and occupational diseases

4. Psychological problem (mental illness/ obesity)

5. Infectious diseases
 TB
 Hepatitis
 Chicken Pox
 Measles
 Others : _______________________

6. Family’s methods of illness Prevention

 Exercise
 Periodic physical examination
 Pap smear
 Immunizations

7. How family cope with stress

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B. FAMILY CHARACTERISTICS

1. Family members living outside the household

Relationship Frequency and

Means of
Name Age to the Location operating
Communication
Household contact

2. Family Mobile
2.1 Length of the current address _______________________________
2.2 Address of Previous Residence _______________________________
2.3 Frequency of geographic moves _______________________________

3. Family dynamics
3.1 Emotional bonding of family members _____________________________
3.2 Distribution of authority and power _______________________________
3.3 How members communicate _______________________________
3.4 How problems are solved _______________________________
3.5 How conflict is handled _______________________________
3.6 Division of labor _______________________________

C. SOCIOECONOMIC AND CULTURAL CHARACTERISTICS

1. Family Social Integration

1.1 Language(s) or dialect(s) spoken _______________________________
1.2 Literacy (ability to read or write in langauge) ________________________
1.3 Network with religious organization _______________________________
1.4 Network with social organization _______________________________

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D. CULTURAL INFLUENCES : Values, Attitudes & Beliefs about:
1. Spirituality _______________________________
2. Rituals (holidays & celebrations) _______________________________
3. Dietary habits _______________________________
4. Health _______________________________
5. Traditional healers _______________________________

E. FAMILY ENVIRONMENT

1. Home

1.1. Ownership ( ) owned ( ) rented ( ) rent-free

1.2. Construction materials used( ) light ( ) mixed ( ) strong
1.3. Adequacy of Size _________________
1.4. Lighting Facilities ( ) electricity ( ) kerosene
( ) others (specify) __________________
1.5. General Sanitary Condition __________________________________________

2. Water Supply

2.1. Drinking water

2.1.1. Ownership ( ) individual (private) ( ) municipal (city owned)

2.1.2. Source ( ) Level 1 (point source)

( ) Level II (communal faucet system or standposts)
( ) Level III (waterworks system or individual
house connections)
( ) open dug wells
( ) unimproved springs
( ) wells not need priming
( ) rain water

2.1.3. Storage ( ) None (direct from faucet or pipe)

( ) jar or can with faucet
( ) jar or can without faucet
( ) others (specify) __________________________

2.2. Water for household use

2.2.1. Ownership ( ) individual / private water system
( ) municipal / city water system
2.2.2. Source ( ) ground water (specify) ____________________

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 ( ) surface water (specify) ____________________
( ) rain water

2.2.3. Storage ( ) home (direct from faucet or pipe)

( ) jar or can
( ) others (specify) __________________________

3. Kitchen
3.1. Cooking Facility
3.2. Sanitary Condition
3.3. Drainage Facility
( ) electric stove ( ) gas stove
( ) firewood / charcoal
__________________________________________
( ) none ( ) open drainage
( ) blind drainage

4. Water Disposal
4.1. Refuse and Garbage
4.1.1. Container ( ) covered ( ) open
( ) none

4.1.2. Methods of Disposal ( ) hog feeding ( ) open dumping

( ) open burning ( ) burial in pit
( ) burial in pit ( ) composting
( ) incineration ( ) collection by government
( ) collection from private
( ) others (specify) __________________________

4.2. Toilet ( ) none ( ) pail system

( ) open pit private ( ) closed pit private
( ) bored hole latrine ( ) overhung latrine
( ) antipolo system ( ) water sealed latrine
( ) flush type
( ) others (specify) __________________________

4.2.1. Distance from the house ____________________________________

4.3. Sanitary Condition ____________________________________

5. Domestic Animals

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 KIND
__________________________
__________________________
__________________________
__________________________
__________________________
NUMBER
___________________
___________________
___________________
___________________
___________________
WHERE KEPT
________________________
________________________
________________________
________________________
________________________

F. FAMILY NEIGHBORHOOD
1. Location ______________________________________________
(urban, rural, subdivision, slum area)
2. Type ______________________________________________
(residential, semi commercial, commercial)
3. Safety
3.1. Traffic pattern _______________________
3.2. Lighting _______________________
3.3. Security _______________________
4. Population density _______________________
(crowding)
5. Sources of pollution
5.1. Air _______________________
5.2. Water _______________________
5.3. Soil _______________________
5.4. Noise _______________________

G. FAMILY HEALTH & HEALTH BEHAVIOR

1. Activities of daily living ________________________________________________
(how family spends a typical day)
2. Health Problems
2.1. Health Deficit / Need: (condition that can be alleviated with medical or social
technology)
____________________________
____________________________
____________________________
2.2. Health Threats (conditions that will promote or cause disease(s) or injury(ies))
____________________________
____________________________
____________________________
2.3. Foreseeable crisis (stressful conditions)
____________________________

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 ____________________________
____________________________

3. Home Remedies
____________________________
____________________________
____________________________

4. Health Care Resources

____________________________
____________________________
____________________________

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