SAINT LOUIS UNIVERSITY

School of Nursing FAMILY NURSING ASSESSMENT TOOL

Address of Family: _________________________________________________________ (House #, Purok or Zone, Street #, Barangay, Municipality, Province) FAMILY NAME: _________________________________________ INFORMANT: _________________________________________ NAME OF HEALTH CENTER: __________________________________ A. FAMILY STRUCTURE, CHARACTERISTICS AND DYNAMICS/RELATIONAL PATTERNS FAMILY MEMBERS RELATIONSHIP TO THE POSITION/ORDER IN THE FAMILY / (include only those HEAD (head, wife of head, OTHER ROLES living in the son, daughter, (Father & breadwinner, mother household. Start from mother/father/in-law, and store keeper, 1st child & the head then niece/nephew, cousin, cleaner, 2nd child and cook, etc.) immediate members househelper, etc) then non-members living with family as last) SURVEYED / DATA GATHERED BY: _________________________________ DATE SURVEYED / GATHERED: _________________________________

BIRTHDATE (month & year)

AGE (should be exact in years and in months)

GENDER

MARITAL STATUS

PLACE OF RESIDENCE / WORK / STUDY (including non-emancipated working or studying family members whether living with family or elsewhere)

DOMINANT DECISION MAKERS IN MATTERS OF: (Please check appropriate column below) HEALTH & MONEY & CARE TENDING EXPENSES

TYPE OF FAMILY: According to structure & composition: ________________________________ According to family head and decision making: _________________________ According to roles/bread-earning : ___________________________________

FAMILY DYNAMICS/COMMUNICATION PATTERNS/INTERACTIONAL PROCESSES: (describe the characteristic communication/interaction patterns between/ among subsystems evidences of love, openness/warmth, caring/helping, listening, ability to handle conflict, change, anticipated and unexpected events; evidences of presence or absence of any obvious or readily observable conflict/s between members, etc.) Spouse subsystem: ___________________________________________________________________________________________________ Parent-child subsystem: ______________________________________________________________________________________________________ Sibling-sibling subsystem: _________________________________________________________________________________________________

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SAINT LOUIS UNIVERSITY

School of Nursing

B. SOCIO-ECONOMIC AND CULTURAL CHARACTERISTICS FAMILY MEMBERS HIGHEST EDUCATIONAL ATTAINMENT (last level completed at the time of survey & none)

RELIGIOUS AFFILIATION RELIGIOUS SECT WHERE WHAT RELIGIOUS SECT IS BAPTIZED THE MEMBER ACTIVE

ETHNIC BACKGROUND

OCCUPATION

INCOME (gathering this data requires non-leading & nonembarassing questions)

OTHER SOURCES OF INCOME

BUDGET AND ACTUAL EXPENSES (Please specify in the table if the budget and expenses is daily, weekly or monthly-based. Questions to elicit this set of data should be very discreet, non-direct and non-embarassing): BASIC NECESSITIES BUDGET ACTUAL EXPENSES CONCLUSION: ADEQUACY TO MEET BASIC NECESSITIES USING THE TOTAL INCOME, BUDGET AND ACTUAL EXPENSES AS BASIS Food and water Adequate (income=budget and actual expenses); inadequate (actual expenses exceeds budget and income); more than adequate (income exceeds actual expenses) Shelter (home maintenance/repairs, rent) Clothing Education Health Electricity, electronics, communication and other services Others (car repair/maintenance, gasoline, etc.) TOTAL SIGNIFICANT OTHERS OF THE FAMILY NAME/S OF SIGNIFICANT MEMBERS

PLACE OF RESIDENCE

ROLES PLAYED IN THE FAMILY

SUPPORT THAT THEY PROVIDE

FAMILY TRADITIONS, EVENTS OR PRACTICES THAT AFFECT MEMBERS HEALTH OR FAMILY FUNCTIONING (please describe): ____________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________

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