COLLEGE OF HEALTH SCIENCES 

NOTRE DAME UNIVERSITY

COTABATO CITY

Surname of Family:TUANSI _______

A. FAMILY STRUCTURE, CHARACTERISTICS AND DYNAMICS

Name Age Sex Civil Status Position in the Living with

Family Family or Not

Bajury 48 M Married Father Yes

Arbaina 43 F Married Mother Yes

Alzerrin 15 F Single Daughter Yes

Al-Khusairy 19 M Single Son Yes

Alee-Zahran 12 M Single Son Yes

Jasmina 63 F Married/Sep. Lola Yes

Arbaya 39 F Single Tita Yes

A.1 Type of Family Structure (e.g. Patriarchal, Matriarchal, Nuclear, or Extended)

Extended - My mother and sister are living with us

A.2 Dominant family member(s) in terms of decision-making especially in matters of health

care:
Both parents

A.3 General Family Relationship/dynamics, characteristic communication, interaction,

patterns among members)

Do the family members talk with one another? How often?

Yes, we always have family conversations everyday. Concerning lifestyle (social media, studies,
health practice), and we talk on each and everyone’s attitude
 B. SOCIO-ECONOMIC AND CULTURAL CHARACTERISTICS

Name Occupation Place of Monthly Educational Ethnic Religion

Work Income Attainment Affiliation
(TRIBE)

Bajury Government BARMM 50k + BS ECE Iranun Islam

Employee
Arbaina Government BARMM 40k BSN Iranun Islam
Employee
Maguindanaon

Alzerrin Student N/A N/A N/A Iranun Islam

Maguindanaon

Al-Khusairy Student N/A N/A N/A Iranun Islam

Maguindanaon

Alee-Zahran Student N/A N/A N/A Iranun Islam

Maguindanaon

Total Monthly income of the Family = ___

B.1 Breakdown of Expenses (Monthly)

Ex.      Food/Groceries = 5k
Electric Bills = 5k
Water Bills = 1k
Transportation = 5k
Allowance for Children’s = 10k

Total Monthly Expenses of the Family =  26k

B.2 Adequacy to meet basic necessities (food,clothing,shelter)

Adequate enough for average standard of living.

B.3 Who makes decisions on money spending 

Both parents, depending on the necessities.

B.4 Significant others (roles they play in family’s life)

Grandfather (maternal side) plays a great role on values formation of the children.

OTHERS: PLEASE SPECIFY

B.5 Relationship of the family to larger community (nature and extent of participation of
the family to community activities or if family member is associated with an organization).
Both parental sides has a family organization for the purpose of reunions and attachment to every
member. As to society, we seldom indulge or participate on usual social obligations.

C. Home and Environment

C.1 Adequacy of Living Space: 

Living space: (Small, wide, approximate area etc.)

300 - 400 sqm. Adequate enough for the 5 family members. There’s a separate space for the lola
and auntie.

How many rooms:

4 rooms. Each kid has their own space

Is the house adequate for the size of the family members?

Yes

C.2 Sleeping Arrangement: 

Average range of time each family member sleeps: (Please specify what time for each member
of the family)
For parents - adequate for an adult but sometimes lesser than the required. For the kids - Mostly
getting sleep late d/t gadgets.

Do family members sleep together or separately?

Most of the time we sleep together. Sometimes they sleep in their own space.

C.3 Presence of breathing or resting sites of vector of diseases (e.g. mosquitoes, flies, and
etc.)

Is the house well ventilated and have adequate lighting?

Yes

Are you living with pets? (If yes, how many? Please specify where they usually stay and any
observed good or bad habits or illnesses)
We have around 10-15 cats, domesticated cats stayed outside while the importeds are staying
inside with proper handling of pets.

Is there any presence of pests in the house? (If yes, please specify.)
Yes, imported cats (2). With proper handling
Are there any accident prone areas present in the house? (If yes, please specify.)
No

C.5 Food Storage and Cooking Facilities:

Food Storage (Please Check.)
Refrigerated 🗸
Not Refrigerated ____
Covered 🗸
Uncovered___

         Cooking Facility
         Electric Stove ____
         Gas Stove 🗸
         Firewood/Charcoal 🗸  

C.6 Water Supply (Source, ownership, portability) (Put a check.) 

         Level I- Point Source (Proacted well or a developed spring) ______
         Level II- Communal Faucet System or Stand Posts (pipe distribution)  _____
         Level III- Waterworks System or Individual House Connections    _🗸 ___  
Others: (Please specify)
       We have our own individual house connections.

C.7 Toilet Facility (Type, ownership, sanitary condition (Please Check.)

         Level I- Non water carriage (pit latrines,pour flush toilet)                       _____
         Level II-Water carriage (water sealed, flushed type with septic tank       ___
         Level III- Water carriage connected to septic tanks to a treatment plan  🗸
Others: (Please specify)
         _______________________________________________________________________
         _______________________________________________________________________

D. HEALTH STATUS OF EACH FAMILY MEMBER

Name Height Weigh BM Vital Signs Past Illness(es) Present

t I Illness(es)

Bajury Tuansi 5’9” 72kg 120/80 Allergic Rhinitis None

Arbaina Tuansi 5’2” 65kg 130/80 Asthma/Cardiac Cardiac

Problem Problem
 Al-Khusairy 5’5” 57kg 120/80 Asthma Treated
Tuansi Hemorrhoids
Alzerrin Tuansi 5’4” 48kg 110/70 Motion Motion
Sickness/Allergi Sickness
c Rhinitis
Alee-Zahran 5’2” 45kg 100/90 Dengue/Allergic None
Tuansi Rhinitis

Treatment/Medication for past Illnesses:

Nebulizer, Beta Blocker, Nasal Spray, ARB’s

FOR ILL MEMBERS OF THE FAMILY

NAME ILLNESSES PHYSICAL LABORATOR TREATMENTS/INTERVENTIONS
DIAGNOSED ASSESSMENT Y OR
OR DIAGNOSTIC
UNDIAGNOSED RESULTS

Arbaina MUP, RHD, Irregular 85% Stress Echo ARB’s, Beta Blockers, Sumapen
Arrhythmia Heartbeats Test (Oral)
Jasmna Asthma Nebulizer

D1. Dietary history(specify quality and quantity of food intake per day) 
Different healthy variants of food served for every meals 3 times a day

D2. Eating/feeding habits/practices (specify what foods family likes to eat usually)
Poultry Products, Dairy, Seafoods, Red Meats, Sometimes processed or ready to eat vegetables
and fruits, and junk foods.

D3. Presence of Risk factor assessment indicating presence of major and contributing modifiable
risk factors for specific lifestyle diseases (please check);

Hypertension: _🗸 __ Physical inactivity:_🗸 __

Sedentary lifestyle: _🗸 __ Cigarette smoking: ____
Elevated blood cholesterol: __🗸 _ Obesity: _____
Diabetes mellitus: ___🗸 __ Inadequate fiber intake: ____
Stress: __🗸 ___ Alcohol drinking:
____
Substance abuse: ____

Others:________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
__________________________

E. VALUES, HABITS, PRACTICES ON HEALTH PROMOTION, MAINTENANCE

AND DISEASE PREVENTION

NOTE: FOR IMMUNIZATION COLUMN, PLEASE FILL OUT IF FAMILY

MEMBERS ARE VACCINATED WITH COVID-19 VACCINE (specify if
complete/incomplete/ incomplete with 1st/2nd dose) (also specify what type of vaccine: Pfizer,
Sinovac, Astrazeneca, moderna, etc)

NOTE: Please also indicate if children are fully immunized since birth.

USE OF
PROMO
REST STRESS TIVE-
USE OF
IMMUNIZ AND EXERCISE/ MANAGEM PREVEN
NAME PROTECTIV
ATION SLEE ACTIVITIES ENT TIVE
E MEASURE
P ACTIVITIES HEALTH
SERVIC
ES
Use of face Proper or
masks, face strict
Vaccinated Adequ shield, Family complian
Bajury Well Managed
(J&) ate frequent use of Outing ce to
alcohol, and health
use footwear protocols
Use of face Proper or
masks, face strict
Mostly
Fully Vac Household and shield, Family complian
Arbaina enoug
Pfizer light exercise frequent use of Outing ce to
h sleep
alcohol, and health
use footwear protocols
Alzerrin N/A Enoug Sometimes Use of face Family Proper or
h sleep masks, face Outing strict
shield, complian
 frequent use of ce to
alcohol, and health
use footwear protocols
Use of face Proper or
masks, face strict
Fully Vac Enoug shield, Family complian
Al-Khusairy Sometimes
Sinovac h sleep frequent use of Outing ce to
alcohol, and health
use footwear protocols
Alee-Zahran N/A Enoug Biking & Use of face Family Proper or
h sleep Basketball masks, face Outing strict
shield, complian
frequent use of ce to
alcohol, and health
use footwear protocols