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Use Long Bond Paper Font style & size: Arial 11 or Tahoma 11 Margins:
Top: Bottom: Left and right: 1 inch 1inch 1 inch

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Page numbers at bottom right Slide folder for individual Ring-bound for grand CP

I. II. III. IV. V. VI. VII. VIII. IX. X. XI. XII. XIII. XIV. XV. XVI.

Introduction Spot Map Family Profile Family Health History Present Health Status IMCI Home & Environment Family Coping Index Schematic Presentation of Family Health Problem Family Health Plan Actual Implementation Recommendation Evaluation Bibliography Appendices Consent letters

A.

Overview of the family

1. Brief description of the family 2. Rationale for choosing the family 3. Main and specific objectives

B.

Scope and Limitations

NOTE: Introduction is only composed of 2 pages.

A.

B.

C.

Narrative description of the route from the point of reference (LdeCU) detailing the streets and major landmarks. Alternative route if an individual travels through regular means. (from terminal to point of destination) Illustration/diagram of the map
1. Legend at the lower left portion 2. Direction arrow at the top right 3. Use valid major landmarks only

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present from the head of the family to the youngest Containing the ff:
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Name Position in the family Gender Age Civil status Birth date Birth place Citizenship Religion Occupation Monthly income

Name Position in the family Gender Age Civil status Birth date Birth place Citizenship Religion Occupation Monthly income

Picture of the family member

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present from the head of the family to the youngest Containing the ff:
Past illness Chronic dis Age at onset Meds/treatment Immunization Childhood dis Sequela Surgery/hospitalization (when, cause, tx/meds) Type of delivery HFD/FDA

present from the head of the family to the youngest Part A. Narrative containing the ff:
Illness; if theres any Mode of onset Treatment/meds Vices
x Smoking or drinking? (since when, # of sticks/bottles)

v/s Part B. Nursing system review chart

Refer to the seminar-workshop for the guidelines

A. B. C. D. E. F. G. H. I.

Housing Water Supply Toilet Kitchen & Cooking facilities Garbage disposal Drainage system Domestic animals Neighborhood Community facilities

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Ownership Construction materials used Estimated size/Adequacy of living space No. of room/Sleeping arrangement Presence of breeding places of vectors Sanitary condition Accident hazards Distance from neighborhood

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Source of drinking water (artesian well-poso, deep well, surface well-atabay) Ownership Potability Distance from the house Storage

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Type (water-seal, flush type) Sanitary condition water-seal type, flush type Unsanitary condition antipolo type Ownership If shared; how many family sharing? Location/Distance from the house

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Location/distance Materials used for cooking Food storage for leftovers

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Type Sanitary condition

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Type Sanitary condition

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Presence of animals Number Kept or astray

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Description of the neighborhood Distance from the nearest neighbor Distance from the health and social facilities

Health and social facilities available

The family owns a house that is made up of light materials (wood and bamboo) about 3 x 3 meters. It is not adequate for them considering they are 6. it is located 500 meters from the health center.

Picture of the house

There are several nails and chemical scattered on the floor. Things are kept untidy and it is seldom swept.

Family Health

Socio-cultural Factors

Biological Factors

Environmental Factors

Socio-cultural Factors

Economic

Political

Cultural

DATA

DATA

DATA

Interpretation/ Implication

Interpretation/ Implication

Interpretation/ Implication

Health Problem/ Condition

Health Problem/ Condition

Health Problem/ Condition

Biological Factors

Genetic

Physical

Psychosocial

DATA

DATA

DATA

Interpretation/ Implication

Interpretation/ Implication

Interpretation/ Implication

Health Problem/ Condition

Health Problem/ Condition

Health Problem/ Condition

Environmental Factors

Housing

H2O

H2O

Toilet

Kitchen

ETC

DATA

DATA

DATA

DATA

DATA

DATA

DATA

DATA

DATA

DATA

DATA

DATA

Imp

Imp

Imp

Imp

Imp

Imp

H Prob

H Prob

H Prob

H Prob

H Prob

H Prob

Computation to be found in the appendices

Details the activities done based on the family health care plan Shows the picture as proof of the activity

Evaluate the objectives found in the introduction

Books and internet sources utilized in the study

Letter of consent for care study ` Letter of consent for taking pictures
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