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CHN - Assessment Guidelines
CHN - Assessment Guidelines
COLLEGE OF NURSING
Name of Members Position Age Sex Civil Status Ethnic Religion Education Occupation
(Pangalan ng bawat (Posisyon sa (Edad) (Kasarian) Background (Relihiyon) (Edukasyon) (Trabaho)
miyembro) pamilya) (Lahi)
B. Patriarchal Matriarchal
C. Who decides in the family especially in matters of health care? (Sino ang nagpapasya sa loob ng pamilya
lalo na kung tungkol sa kalusugan?): _____________________________________________________
E. Siginificant others and role (s) they play in the family’s life. (Mga importanteng tao at ang kanilang
ginagampanan sa buhay pamilya)
1. _________________________________________ 3. ________________________________________
2. _________________________________________ 4. ________________________________________
Type of Occupation (Uri ng hanapbuhay): Blue Collar Job White Collar Job
BCJ WCJ
( ) Electrician ( ) Office Manager
( ) Plumber ( ) Accountant
( ) Mechanic ( ) Engineer
( ) Construction Worker ( ) Manager
( ) Welder ( ) Physician
( ) Others, Please Specify:________________ ( ) Others, Please Specify:________________
Who decides about money and how is it spent? (Sino ang nagdedesisyon kung paano gagamitin ang pera?)
____________________________________________________________________________________
Monthly Expenses:
Housing: Utilities: Food and Groceries:
( ) Electricity:_______________
( ) Water:__________________
( ) Heating:_________________
( ) Fuel ( ) Insurance
( ) Public
Transportation:_______________
3. With cleaning facility faucet w/ running water and sink pail w/ water and sink
Pail w/ water and open pit
Drinking storage (Inumin): None (direct from faucet or pipe) Large covered without faucet
cockroach rodent
g. Presence of accident hazards
Are there any of the following: broken stairs pointed objects (please specify) ______
poisons fire hazards
fall hazards improperly kept medicines
others (specify) ______________________
h. Toilet facility (Palikuran):
LEVEL I Pit latrines reed odorless earth closet pour flush toilet aqua privy
LEVEL II Flush type water sealed toilet with septic tank
LEVEL III Flush type water sealed toilet sewerage system/ treatment plant
k. Domestic Animals
II. Neighborhood
Kind of Neighborhood (uri ng komunidad): congested ( dikit – dikit) not congested (hindi dikit – dikit)
Is it safe to go out at night? (Delikado ba lumabas sa inyong lugar kapag gabi?) Yes No
If there is trouble in the neighborhood, how often does it happen? (Kung magulo, gaano kadalas ang
kaguluhang nangyari?) :
B. Social Facilities (Lugar ng pagpupulong / salu – salo) court (payo) Brgy. Hall
_________________________________________________________________
Name of the family Age (Gulang) Disease Medical Attendant Medications and
members (pangalan (sakit/ karamdaman) Treatments
ng miyembro) received (natanggap
na lunas)
Name of the family Age (Gulang) Disease Medical Attendant Medications and
members (pangalan (sakit/ karamdaman) Treatments
ng miyembro) received (natanggap
na lunas)
FAMILY MEDICAL HISTORY
Mother side
Diabetes Hypertension Cancer Asthma Others
Specify _________________
Father Side
Diabetes Hypertension Cancer Asthma Others
Specify _________________
HOSPITALIZATION:
Vaccines (CHOICES)
Remarks (CHOICES):
BCG DPT OPV Hepatitis B Measles Others pls. specify
Complete Incomplete
MEDICAL CARE
Goes for check – up only when ill or have signs and symptoms