INITIAL DATA BASE FORM

I. FAMILY STRUCTURE, CHARACTERISTICS and DYNAMICS

A. Members of the Household and relationship to the head of the Family

B. Demographic Data

Name Birthday Age Sex Position in the

family

C. Place of residence of each member

D. Type of Family Structure

a. Nuclear (accdg to membership)
b. Matrilocal (accdg to residence)
c. Matricentric (accdg to authority)
d. Dominant family members in terms of decision making

GENOGRAM

E. General Family Relationship:

F. Activities of Daily Living

a. Sleeping pattern and daily activities
b. Eating pattern
c. Leisure time

II. SOCIO-ECONOMIC and CULTURAL CHARACTERISTICS

Income and expenses

Name Position in the Occupation Income Place of work

family
 Show the graph of approximate income allocation of the family using a pie chart.

Educational attainment, Religious affiliation and Cultural factors of the family

Name Position in the Educational School Ethnic Religion
family attainment background

Relationship of the Family to larger community

III. HOME and ENVIRONMENT

Housing:
a. Adequacy of living space
b. Sleeping arrangement
c. Presence of breeding or resting sites of vectors of diseases
d. Presence of accidental hazard
e. Food storage and cooking facilities
f. Water supply
g. Toilet facilities
h. Garbage/refuse disposal
i. Drainage system
Kind of neighbourhood
Social and health facilities available
Communication and Transportation facilities available

IV. HEALTH STATUS OF EACH FAMILY MEMBERS

Medical and Nursing history indicating current or past significant illnesses or beliefs and practices
conducive to health and illness
Nutritional Assessment
Name Age Height Weight BMI

V. VALUES, HABITS, PRACTICE ON HEALTH PROMOTION, MAINTENANCE and

DISEASE PREVENTION
A. Immunization status of the Family members

Name BCG DPT MMR HEPA OPV

Adequacy of:
a. Rest and sleep
b. Exercise and activity
c. Use of protective measures
d. Relaxation and other stress management activities
e. Use of promotive-preventive health services
f. Perception of the role of health professionals and their services
g. Past experiences with health professionals

VI. HEALTH TEACHINGS