FATHER SATURNINO URIOS UNIVERSITY

San Francisco St. Butuan City 8600, Region XIII

Caraga, Philippines
Nursing Program

INITIAL DATABASE

A. FAMILY STRUCTURE AND CHARACTERISTICS

1. Members of the Household and Relationship to the Head of the Family
Family Member Birth Date Age Sex Position Remarks

2. Place of Residence in Each Member

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3. Type of Family Structure
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4. Dominant Family Members in Terms of Decision Making Pertaining in Health Matters
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5. General Family Relationship
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B. SOCIO-ECONOMIC AND CULTURAL FACTORS
1. Income and Expenses
a. Occupation, Place of Work, and Income of each Family Member
Family Member Occupation Place of Work Income
 b. Adequacy to Meet Basic Needs
Quantity Item Unit Price Total

Note: If you have a lot of items to list down, you may use a separate sheet.
c. Who makes decision about money spending
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2. Educational Attainment of Each Member
Family Member Educational Attainment School Year

3. Ethnic Background and Religious Affiliation

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4. Relationship of Family to the Community
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C. ENVIRONMENTAL FACTORS
1. Housing
a. Adequacy of Living Space
(Please make a diagram of the house with measurements or use a separate sheet)

b. Sleeping Arrangement
(Please make a diagram of the house with measurements or use a separate sheet)

c. Adequacy of Furniture
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d. Presence of Insects and Rodents

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e. Food Storage and Cooking Facilities
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f. Water Supply
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g. Toilet Facility
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h. Garbage and Refuse Disposal
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i. Drainage System
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2. Kind of Neighborhood
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3. Social and Health Facilities Available
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4. Communication and Transportation Available
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D. Health Assessment of Each Member

1. Medical and Nursing History of Past Significant Illness and Whom to Approach in Times of
Illness?
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2. Nutritional Assessment
a. Anthropometric Data
Family Member Weight Height BMI Interpretation

b. Dietary History
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c. Eating Feeding Habits
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3. Current Health Status in Indicating the Presence of Illness
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E. VALUE PLACED ON PREVENTION OF DISEASE
1. Immunization Status of Children
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2. Use of Proper Preventive Services
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