0% found this document useful (0 votes)
15 views13 pages

Family Data Collection Template

Uploaded by

Jane Balandra
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
0% found this document useful (0 votes)
15 views13 pages

Family Data Collection Template

Uploaded by

Jane Balandra
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

UNIVERSITY OF BOHOL

COLLEGE OF NURSING

City of Tagbilaran

INITIAL DATA BASE

Family Surname :_________________ Name of Family Head:_______________

House No.:_____Street:_______________________ Purok Number:__________

Purok Name: ______________Barangay:__________ Municipality:___________

Source of Information:_________________________ Relation:______________

Data gathered by:_____________________________ Date : _______________

A. Household members:

No. Family Se ag Civil Relatio Religion Educational Occupation


Members x e status n to Attainment
Head
B. Family Characteristics:
Type of family structure:

( ) Nuclear family ( ) Dyad family ( ) Compound family

( ) Extended ( ) Blended family ( ) Cohabiting family

( ) Single parent family

Family Members living outside the household

Name Age Relationshi Location Occupation Frequenc Means of


p to head of / y of communicatio
Member Work contacts n

Family Mobility:

Length of time of current address:______________

Address of previous residences : ________________________________________

Frequency of geographic moves: ________________________________________

Family Dynamics :

Emotional bonding of Family members __________________________________

Distribution of authority and power ____________________________________


How members communicate __________________________________________

Dominant Family Members in terms of decision making

( ) Husband ( ) Adult children

( ) Wife ( ) Others, specify:_________________________

How problems are solved _____________________________________________

How conflict is handled _______________________________________________

Division of labor_____________________________________________________

C. Socio-economic and cultural characteristics:


Family social integration:
Language(s) or dialects (s) spoken
( ) visayan/ Cebuano ( ) tagalog
( ) english ( ) others specify,________________________

Literacy ( ablility to read or write in language (s)


( ) Yes
( ) No

Degree of social network with friends, neighbors and other


relatives________________________________________________________

Networks with religious organizations ( name of religious organizations, the


family members are involves ______________________________________

Networks with social organizations ( Name of organizations the family is


involved) ______________________________________________________

Educational experiences _________________________________________


Work experiences ______________________________________________
Adequacy of financial resources :
Monthly family income source:
( ) Husband : __________________
( ) Wife :___________________
( ) Others, specify :___________________

Monthly family income : ( Total ) Please check bracket


( ) Below 5,000
( ) 6,000- 10,000
( ) 11,000 – 15,000
( ) 16,000 – 20,000
( ) 21,000 – 30,000
( ) 30,000 – 40, 000
( ) 40, 000 – 50,000
( ) above 50,000

Felt Family needs:


( Identify and rank according to priority)
1.

2.

3.

4.

5.

Leisure time interest: ( Name some leisure time activities) ______________

______________________________________________________________

D. Cultural influences :values attitudes, and beliefs about:


Spirituality : ____________________________________________________
Rituals : ( Holidays and celebrations ) _______________________________
Dietary habits : _________________________________________________
Health : _____________________________________________________
Folk diseases : ________________________________________________
Traditional healers: ____________________________________________

E. Family and environment :


1. Home
a. Ownership
( ) owned ( ) rented ( ) rent-free
b. Construction materials used
( ) light ( ) mixed ( ) strong
c. Number of rooms used for sleeping: ___________
d. Lighting facilities
( ) electricity ( ) kerosene ( ) others, specify:
______________
e. General sanitary condition_________________________________
2. Drinking and water supply:
a. Source
( ) level 1 – ( point source)
( ) shallow or deep well
( ) Improved dug well
( ) developed spring
( ) rain tank
( ) level 2 – communal faucet
( ) waterworks system
( ) water refilling station
b. Distance from the house _______________
c. Storage :
( ) None ( direct from the faucet)
( ) large covered container with faucet ( water dispenser, jars,etc)
( ) Large uncovered container without faucet
( ) others, specify
3. Kitchen
a. Cooking facility used:
( ) electric stove
( ) gas stove
( ) firewood/charcoal
( )others specify: __________________

b. Food storage:
( ) covered
( ) uncovered
( ) refrigerator ( container with cover )
( container without cover)
c. Sanitary condition : ___________________
d. Drainage facility of kitchen :
( ) open drainage
( ) blind drainage
( ) none

4. Waste disposal:
a. Garbage container
( ) covered ( ) open ( ) none
b. Method of disposal:
( ) hog feeding ( ) open burning
( open dumping ( ) garbage collection
( ) burying in pit ( ) others, specify
( ) composting

c. Excreta disposal:
( ) tanked flush toilets ( connected to septic tanks and /or sewerage

system)

( ) Pour – flushed latrine


( ) ventilated – improved pit latrine ( VIP)
( ) overhung latrine
( ) antipolo toilet
( ) pit latrine
( ) box- and- can privy
( ) shared
( ) none
d. Distance from the house : _________
e. Sanitary condition : ( describe briefly the state of cleanliness)
__________________________________________________

5. Domestic animals / common household pets:

Kind Number Where kept

6. Pest and vermin control:


a. Presence of breeding sites of insects, rodents, etc
( ) yes, specifically: _________________________
( ) No

7. Presence of accident hazards:


( ) yes ( ) No
If yes, specify:
( ) broken parts of the house ( ) slippery pathways
( ) sharp objects ( unkept)
( ) medicine ( unkept)
( ) broken glasses
( ) unkept animals
F. Family Neighbourhood
a. Location
( ) urban
( ) rural
( ) subdivision
( ) slum area

b. Type of neighbourhood
( ) residential
( ) semi-commercial

c. Safety
( ) traffic patterns
( ) lighting
( ) security ( police or pvt.)
( ) pedestrian lanes
( ) walking pathways

d. Population density ( crowding)


( ) congested
( ) non- congested

e. Sources of pollution
( ) air
( ) water
( ) soil
( ) noise

f. Social and health facilities available


( ) BHS ( ) Chapel
( ) RHU ( ) senior citizens’ building/hall
( ) Pvt. Clinics/hospital
( ) barangay hall
( ) basketball court
( ) purok kiosk/ centers

g. Communication facilities of the family:


( ) Cellphones
( ) Landline telephones
( ) Internet

h. Transportation facilities :
( ) Public Utility vehicle/Jeepneys ( PUV/ PUJ)
( ) Owned pvt. Cars
( ) owned motorcycles
( ) rented vehicles

G. Family Health and health behaviour


a. Activities of daily living ( how family spends a typical day)
_______________________________________________

b. Health history :
1. Pregnancy –
________________________________________________
________________________________________________

2. Illness - __________________________________________
_________________________________________________

3. Death within the past 5 years :


( ) Yes ( ) None
If yes, indicate cause of death: ________________________

4. Health attendance: ( How often)


( ) every month ( ) once a year
( ) as the need arises ( ) never
( ) others, specify: ______________________

c. Self care activities: ( Name family’s related activities)

Health promotion :

Disease prevention :

d. Risks factor assessment for specific lifestyle diseases:


( ) hypertension ( ) obesity
( ) physical inactivity ( ) diabetes mellitus
( ) sedentary lifestyle ( ) inadequate fiber intake
( ) cigarette/ tobacco smoking ( ) stress
( ) elevated lipids/ cholesterol ( ) poor diet
( ) alcohol drinking ( ) other substance abuse
( )others, specify: ______________________________________

e. Present Health status:


Father / family head : ___________________________________
Vital signs:
T - ___________ BP- ___________ HR - ________ RR-___________
Physical complaints : ______________________________________

Mother /Wife : ____________________________________________

Vital signs :

T - __________ BP-___________HR- _________ RR- ___________

Physical complaints: _______________________________________


________________________________________________________

Other Family members:____________________________________

Vital signs:

T- _________ BP -_________ HR - _________ RR- _____________

Physical complaints: ______________________________________

_______________________________________________________

f. Common Illnesses encountered and management applied :

Age Illness Management


0–1

1 -3

3–6

6–7

7 – 12

13 – 18

19 – 25

26 – 35

36 – 45

46 – 50

51 - 55

56 – 60
60 and
up

g. Health care resources


a. Where do you consult for health related problems?
( ) manghihilot ( ) RHU’s ( MHO, PHN, PHM)
( ) Pvt. Clinics/ Doctors ( ) alternative Treatment clinics
( ) BHW’s ( )others, specify: _______________
b. For problems other than health, whom do you consult?
( ) family members ( ) relatives
( ) friends ( ) Barangay officials
( ) Priest ( ) Health workers
( ) others, specify:__________________________

c. Immunization status of children :


1. Are the children immunized ?
( ) Yes ( ) No ( ) Incomplete
Why: __________ Why: __________

2. If yes, check immunization if they had :


( ) BCG ( ) Hep B Vaccine
( ) OPV ( ) AMV
( ) Pentavalent Vaccine ( ) MMR
( DPT, HepB, Hib ) ( ) Others, specify:______________

d. Adequacy of :
1. Rest and sleep
( ) Yes ( ) No
If No, Why? : __________________________
2. Exercise/ Physical activity
( ) Yes ( ) No
If No, Why? ___________________________
[Link] management activity/ relaxation
( ) Yes ( ) No
If No, why? ___________________________
If yes, how often?
( ) daily
( ) three times a week
( ) once a week
( ) once a month
( ) never
( ) Others, specify: ______________________

Common questions

Powered by AI

The type of family structure can significantly impact both emotional bonding and the distribution of authority within a household. For example, in a nuclear family, which typically consists of two parents and their children, emotional bonding may be very close-knit due to fewer family members, leading to more egalitarian distribution of authority among members. In contrast, an extended family, which includes additional relatives such as grandparents or aunts and uncles, may see a more hierarchical distribution of authority based on age or role, which can affect the closeness of emotional bonds by creating sub-group dynamics .

Inadequate sanitation and waste management practices can lead to significant health risks including the spread of infectious diseases, increased vermin and insect infestation, and the contamination of water sources. Poor waste disposal methods, such as open burning or dumping, can compromise air quality and lead to respiratory issues. Similarly, open or uncovered garbage containers may attract pests, leading to vermin-related diseases. Improper excreta disposal further exacerbates health risks by potentially adding pathogens directly into the home environment .

Family healthcare decisions are influenced by cultural attitudes, which may prioritize traditional medicine over or alongside modern medical practices. Families rooted in cultural beliefs that emphasize traditional healers or remedies may choose them first for their perceived spiritual or historical significance. Conversely, acceptance of modern medical practices often depends on the education level and exposure to health information advocating scientific effectiveness. These attitudes can also dictate the response to vaccination, preventive care, and the overall approach to healthcare .

The presence of domestic animals can have both positive and negative implications for family health and sanitary conditions. Positively, pets can enhance mental health by providing companionship and stress relief. However, without proper care and hygiene, they can also pose health risks, such as zoonotic diseases, and affect sanitary conditions through waste and fur, potentially aggravating allergies. The way animals are kept and their proximity to living spaces greatly influences these outcomes .

Frequent family mobility and changing addresses can disrupt community integration and weaken social networks. Regular moves can break existing social ties and hinder the establishment of stable relationships with neighbors and within social organizations. This lack of community stability may limit access to local support systems and impact participation in community activities, thereby reducing social integration and potentially leading to feelings of isolation .

Socio-economic characteristics like monthly family income and educational attainment significantly influence lifestyle choices and health behaviors. Families with higher income levels typically have better access to health resources, enabling them to afford healthier food options, regular medical check-ups, and engage in physical activities that contribute positively to health. Additionally, education can inform better health practices, reduce risky behaviors such as smoking, and promote preventive health measures .

Integration with social and religious organizations can significantly enhance family health and well-being by providing emotional support, promoting healthy behaviors, and offering social networks that contribute to a sense of belonging and purpose. Such organizations often provide avenues for educational activities, health screenings, and the dissemination of health promotion information, thereby directly impacting health awareness and preventive practices. Furthermore, these connections can foster community engagement, reducing stress and improving mental health outcomes by building strong support systems .

Family leisure activities can be closely tied to the felt needs of family members as they often reflect the desire for relaxation, togetherness, and personal growth. Leisure activities that involve all family members may address the need for quality bonding time, while individual hobbies may cater to personal fulfillment or stress relief. The choice of leisure activities can also reflect underlying socio-economic priorities, signifying the balancing act between work pressures and family aspirations .

Transportation and communication facilities are critical in determining a family's access to health and social services. Efficient transportation such as owned or public vehicles facilitates the timely and reliable travel to health appointments, critical in emergencies or routine care. In parallel, communication facilities like cellphones and the Internet enhance the ability to seek appointments, access telehealth services, and remain informed about health matters and social opportunities. These infrastructures thus play a pivotal role in comprehensive health management and social engagement .

Cultural values and traditions play a crucial role in shaping dietary habits and health beliefs within families. Rituals and traditional celebrations often dictate specific foods that are consumed, influencing dietary patterns both daily and during special occasions. Health beliefs can also be shaped by cultural values, where reliance on traditional healers and beliefs in folk diseases may affect how a family approaches medical treatment and prioritizes health. These cultural components can sometimes contradict modern medical practices, impacting the adoption of preventive health behaviors .

You might also like