Comprehensive Assessment Tool

For Family Health Nursing

Utilizing Betty Neuman Model

Biographic Data

Name Age Sex

Birthdate Civil Status

Occupation Religion

Address

Past Health History Family History of Illness

Vital Signs
Blood Pressure:  Lying  Sitting  Standing
Heart Rate: Rhythm:
Respiratory Rate: Rhythm:
Temperature:
Weight: kg
BMI: kg/m2
 INTRAPERSONAL
PHYSIOLOGICAL VARIABLE
• How do you describe your current health? Describe:
• Do you take any medications? No
If yes, what medications you are currently
taking and what are their purposes? Yes, Specify:
• Do you have visual, hearing or speech No
problems?
If yes, since when it was started? Yes, Specify:
• Do you need help from others to perform No
everyday activities such as eating, getting
dressed, grooming, bathing, walking, or using Yes, Specify:
the toilet?
• Do you use assistive devices such as glasses, No
hearing aid, wheelchair or cane?
If yes, since when it was started? Yes, Specify:
• What are your usual activities or leisure every Describe:
day?
• What are the activities that you cannot do or Describe:
limit yourself from doing due to your current
health
• Describe your typical food and water intake. Describe:
• What foods do you need to avoid or limit due Specify:
to your current health?
• For the past 7 days, do you experience trouble No
in sleeping?
Yes
• Do you use sleeping aids? No
If yes, how often?
Yes, Specify:
• Do you smoke or drink alcohol? No
If yes, since when it started and how often?
Yes, Specify:
• Do you experience difficulty or pain in any No
parts of your body?
Yes, Specify:

Location/Part:
Quality of pain:
• In your understanding what may be the trigger Describe:
of the symptoms?
• What do you usually do to relieve the Describe:
difficulties or pain?
• Pain Scale of 1-10

PSYCHO-SOCIOCULTURAL VARIABLE
• What is the common reason of your stress?
 Nothing  I don’t know  My Illness  My Family  Financial
Others, Specify:
• How do you react when you are stressed?
 Nothing  I don’t know  Cry  Silent  Angry
Others, Specify:
How do you handle stressful situation?

What are your beliefs and practices?

Do you have any practices in treating pain or illness?
 No
 Yes, Specify please;
• Are you confident about yourself? Never Sometimes Always

• How often do you feel emotional problems

such as anxiety, anger, depressed or irritable?
• Are you able to control your emotions in
stressful situations?
• How often do you get yourself check by a
Doctor?

Developmental Variable
What is the highest level of education you have completed?

 None  High School  College

 Elementary  Technical Training (TESDA)
Are you currently working?
 I never work
 No longer working; how long you stop working? _____
 Part-time
 Full-time work
What is your role in your family?

Spiritual Variable
What things do you believe in that give meaning in your life?

What are the elements of medical care forbidden based on your religious grounds?

Do you practice praying to treat illness?

INTERPERSONAL
How is your living arrangement?
 Living alone  Living with spouse and child  Living with parents
 Living with spouse  Living with siblings  Living with relatives
How is your relationship with your partner?
How is your relationship with your family and relatives?

Do you have a good support system?

Do you have difficulty in getting along with others?
When highly stressed, are you likely to ask friends or relatives for help?
What are the common conflicts you had with your family
 Nothing  I don’t know  My Illness  Financial
Others, Specify:

EXTRAPERSONAL
• How often do you engage or communicate Never Sometimes Always
with your family?
• How often do your family experience
conflicts?
• Do you feel the presence of your family
support?
• Do you feel the presence of community
support?
• Do your family support you financially?
• Do your friends and family gave you
emotional support?
• Do you have a good relationship with your
caregiver?