University of San Agustin

College of Health and Allied Medical Professions

Iloilo City

COMMUNITY HEALTH NURSING - INITIAL DATA BASE

Name of Interviewer: ________________________________________ Course & Year: ______________

C.I. Assigned: __________________________________________________________________________
Date Conducted: ___________________ Time Started: _______________ Time Ended: ______________

Name of Respondent (Optional) Position in the Family Age (18 & Above)

Zone / Sitio Barangay Municipality

I. Family Structure, Characteristics and Dynamics

A. Members of the Household
FAMILY MEMBER S BIRTHDATE OCCUPATION REMARKS/
No Name POSITION RELATION E MM Age MARITAL HIGHEST Type Monthly DATE
. IN THE TO HEAD X /DD STATUS EDUCATION of income ENTERED
FAMILY /YY COMPLETED work

1.
2.
3.
4.
5.
6.
7.
8.

B. Type of Family Structure Patriarchal Matriarchal Nuclear Extended Blended

C. Who are the dominant Family Members in terms of decision making?
__________________________________________________________________________________
D. What is the general family relationship/dynamics? (Is there a presence of any obvious/readily
observable conflict between members; characteristics, communication/interaction patterns among
members?)
___________________________________________________________________________________
___________________________________________________________________________________
________________________________________________________________________________
__________________________________________________________________________________
 University of San Agustin
College of Health and Allied Medical Professions
Iloilo City

II. Socio-Economic and Cultural Characteristics

A. Income and Expenses
o Occupation  Unemployed  Without permanent employment
 With permanent employment
o Adequacy to meet basic needs.  Able to buy food everyday  Able to buy clothing
 Able to buy materials for the house
o Who makes decisions about money and how it is spent?
______________________________________________________

B. Religious Affiliation:
o Christian:
 Roman Catholic  Protestant  Baptist  Seventh Day Adventists
 Iglesia ni Cristo  Jehovah’s Witness  Evangelical Christianity (Born Again)
 Church of Jesus Christ of Latter-Day Saints (Mormon)
o Other major religions:
 Islam (Muslim)  Judaism  Hinduism  Buddhism  Sikhism
 Rizalista  Pls. Specify: ___________________________

C. Family Traditions:
o What are the events or practice affecting members’ health or family function?
__________________________________________________________________________
______________________________________________________________________

D. Significant Others:
o Who are those non-family members that play a significant role in the life of the family?
__________________________________________________________________________
______________________________________________________________________
E. Relationship of the Family to the Larger Community:
o What is the nature and extent of participation of the family in community activities?
__________________________________________________________________________
______________________________________________________________________
III.
Home and Environment
1. Housing
o Ownership:  Owned  Rented  Rent-Free
o Construction Materials used:  Light  Mixed  Strong
o Number of rooms used for sleeping: _____________________________
o Lighting facilities:  Electricity  Kerosene
 Others, specify: ___________________
 University of San Agustin
College of Health and Allied Medical Professions
Iloilo City

a. How is the adequacy of living space?

_____________________________________________________________________
b. How is the family’s sleeping arrangement?
_____________________________________________________________________
c. Is there any presence of breeding or resting sites of vector of diseases (e.g. mosquitoes,
roaches, flies, rodents, etc.)
 No  Yes, where are they located?
_____________________________________________________________________
d. Is there a presence of accident hazard?
 No  Yes, where are they located?
_____________________________________________________________________
e. How is the food being stored and what are the different cooking facilities that they use?
_____________________________________________________________________
f. Water supply-source:
 Private  Public Main Source: ____________ Potability: _________________
g. Toilet Facilities:
o Type  None  Pail system  Overhung Latrine  Antipolo Type
 Open Pit Privy  Close Pit Privy  Bored-hole Latrine
 Flush Type  Water-sealed Latrine
 Others, specify: ______________________________
o Distance from the house:
___________________________________________________________________
o Sanitary Condition:
___________________________________________________________________
h. Garbage / Refuse Disposal:
o Container Type  Covered  Open None
o Method of Disposal  Hog Feeding Open Burning Open Dumping
 Burial in pit  Composting
 Garbage Collection
 Others, specify: _______________________
o Sanitary Condition:
___________________________________________________________________
i. Drainage System
o Type Open Drainage  Blind Drainage  None

o Sanitary Condition:
___________________________________________________________________
 University of San Agustin
College of Health and Allied Medical Professions
Iloilo City

2. Kind of Neighborhood
a. Housing Congestion  Yes  No
b. General sanitary condition of the community:
_________________________________________________________________
3. What are the Social facilities available in the area?
_______________________________________________________________________
4. What are the Health facilities available in the area?
_______________________________________________________________________
5. What are the means of communication available?
________________________________________________________________________
6. What are the types of transportation facilities available?
_________________________________________________________________________

IV. Health Status of Each Family Member

A. Medical Nursing history indicating current or past significant illnesses or beliefs and practices
conducive to health and illness

FAMILY MEMBER Past Allergies Accidents / Hospitalization Medications

No Name Illnes Injuries (Reason/When (Drug/Dose/
. / Where) Frequency)
1.
2.
3.
4.
5.
6.
7.
8.

B. Nutritional Assessment

FAMILY MEMBER Anthropometric Data Dietary History Eating Habits/

Practices
No. Name Weight Height BMI Classification Medications
(kg) (cm)

1.
2.
3.
4.
5.
6.
7.
 University of San Agustin
College of Health and Allied Medical Professions
Iloilo City

C. Developmental assessment of infant, toddlers and preschoolers.

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
D. Risk factor assessment indicating presence of major and contributing modifiable risk factors for
specific lifestyle diseases.
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
E. Physical Assessment indicating presence of illness state/s (diagnosed or undiagnosed by medical
practitioners)
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
F. Results of laboratory/diagnostic and other screening procedures supportive of assessment
findings.
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

V. Values, Habits, Practices on Health Promotion, Maintenance and Disease Prevention.

FAMILY MEMBER Immunizations / Vaccinations

No. Name BCG HEPA B DPT HIB OPV IPV PCV MMR HPV Influenza Varicella
1.
2.
3.
4.
5.
6.
7.
8.
 University of San Agustin
College of Health and Allied Medical Professions
Iloilo City

FAMILY MEMBER Adequacy of:

No Name Healthy Rest Exercise/ Protective Relaxation &

. Lifestyle and Activities Measure Stress
Practices Sleep Management
1.
2.
3.
4.
5.
6.
7.
8.

A. What promotive-preventive health services do you avail in the Health Centers / your Community?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________