CN 104 - Community Health Nursing 1

INITIAL DATABASE of the FAMILY

1st Level Assessment

Name: _____________________________________________________ Date: _________________________________

Student Number: _____________________________________________ Rating: ________________________________
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FAMILY INFORMATION

Name of Family : _________________________________ Type of Family based on Composition______________

Address : _______________________________________

A. Family Structures and Characteristics

Name of Members of Family Age in Sex Civil Position in the Family & Role in the family
Years Status Relationship to the
Head
1
2
3.
4
5
6
7
8
9
10

General Description of the Family Structure

(This section discusses the general nature of the family as to types based on authority, descent, and other data)

B. Socio-economic and Cultural Characteristics

1.Income and Expenses

Name of Members of Age in Occupation Place of Work Approximate Income of

Family Years each working member
per month
1.
2
3
4
5
6
7
8
9
10
TOTAL MONTHLY INCOME P/
Breakdown of Family Expenses (per month)

Types of Utilities Amount to pay per month

Water
Electricity
Internet subscription
Food
Gasul/ Kerosene for cooking
Others

Description of economic status of the family

(This section discusses the conclusion on whether income is enough to cover the monthly expenses of the family
and Who makes decisions about money and how to spend)

2.Educational attainment, ethnic background and religious affiliations

Name of Member of Family Educational Attainment Types of Religion Affiliation

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

3. Ethnic Background

4. Significant Others

5. Relationship of the Family to the Larger Community

C. Home and Environment

1. Housing

1.1. adequacy of living space

1.2. sleeping arrangement of family members

1.3. presence of breeding or resting sites of vectors

1.4. presence of accident hazards

1.5. food storage and cooking facilities

1.6. water supply

1.7. Toilet facility

1.8. Garbage Disposal

1.9. Drainage System

2.Kind of Neighborhood

3.Social and Health Facilities Available

4. Communication and Transportation Facilities Available

D. Health Status of Family Member

1.Medical and Nursing History

2.Nutritional Status

Name of Age Waist Hip Waist- Desirable Interpretation

Members in Circumference Circumferenc Hip Height Weight Body of Nutritional
of Family years (cm) e Ratio (inches (kg) Weight Status
(cm) )
1
2
3
4
5
6
7
8
9
10

Dietary History/ Eating and Feeding patterns

3.Developmental Assessment for Infants, Toddler and Preschooler

4.Risk factor Assessment

5. Result of Direct Examination

6. Results of Laboratory/ Diagnostic and other screening procedures

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

1.Immunization Status (Children 0-5 years old) as well as the Adult member

Types of Vaccine received Received Covid Vaccine

Name of Member of Family Age in Years For 0-5 years old
Types No. of dose
1
2
3.Maria 5 BCG,Hepa,OPV,Pentavalen pfizer 2
4
5
2.Healthy Lifestyle Practices

3.Rest and Sleep

4. Exercise and Relaxation

5. Use of Protective Measures

6. Use of Preventive and promotive Health Services