Makati Medical Center College of Nursing
144 Legaspi Corner V.A. Rufino St., Libran House, Legazpi Village, Makati City
Family Database
Name of Interviewee: Flor De Liza J. Acua
Pio Del Pilar
Religion: Catholic
Place of Origin: Manila
Members: 5
Age: 36 y/o
House #: 7157
Purok/Barangay:
Length of Residency: 36 years
Number of Family
A. FAMILYDATA
1. FAMILY MEMBERS
Names
Date of
Birth
Age
Sex
Estelita Acua (Mother)
09/03/194
3
72 y/o
Female
Dolce Acua (Sister)
08/20/197
5
39 y/o
Vince Christian Labasa (Baby)
12/09/200
6
Ryza Cassandra Yu (Baby)
(Buie)
Bienveniedo
(Brother)
Jezi Maey Acua (Baby)
Acua
Civil
Status
Education
Attainment
Occupation
Income
Grade 6
Level
Dressmaker
P3,000
Female
Vocational
Course
Call Center
(Encoder)
P9,000
8 y/o
Male
Grade 3
Student
06/14/200
5
10 y/o
Female
Grade 5
Student
11/29/1973
40 y/o
Male
College
Level
Collector of
Payment
P10,000
05/29/201
5
1 mo.
Female
1. FAMILY STRUCTURE AND CHARACTERISTICS
2.1 Family Structure
( ) Nuclear ( ) Two career Single Parent ( ) Adolescent Family ( x) Blended ( ) Cohabiting
( ) Gay and lesbian
( ) Extended
2.2 Base on Authority
( ) Patriarchal (x) Matriarchal
( ) Egalitarian ( ) Matricentric
2.3 Stages of Family Relationships ( ) Beginning
( ) Child Bearing (x) Family with Preschoolers ( ) With School
Age ( ) Teenagers & Young Adults
( ) Post Parental
( ) Aging
2.4 Dominant in Decision Making
(x) Mother ( ) Father
( ) Both
( ) Others ___________
2.5 General Family Relationships/Dynamics (x) Highly Favorable
( ) Moderately Favorable
()
Unfavorable Remarks: (Describe briefly) _____
2.6 Significant Others (Indicate roles they play in the familys life) Jerry Yu (Husband)
2.7 Relationship of the family to the larger Community (Describe the nature and extent of participation) When there
are events they participate.
2.7.1 Activities Attended: (x) Barangay Assembly
( ) Clean-up Drives
( ) Health Teachings
()
Seminars
2.7.2 Extent of Participation: (x) Always ( ) Most of the Time ( ) Sometimes
( ) Seldom
( ) Never
2. HomeandEnvironment
3.1 ConstructionMaterialsused: () Strong
3.2 Home Ownership:
3.3 LightingFacilities:
3.3.1
(x) Electricity () Kerosene Lamp
3.3.2
() Adequate () Inadequate
3.4 CookingFacility:
3.4.1 Sanitary Condition
3.5 DrainageFacility:
3.6 Numberofbedrooms:
more
(x) Owned
(x) Light
() Rented
(X) Electricstove () Gasstove
() Good
() Poor
() None
() None
() Mixed
() Makeshift
() Rentfree
() Kerosene
() firewood/charcoal
() Opendrainage (x) Blinddrainage () Others:
() 1
(x) 2
() 3 or
Remarks: (Describe the Familys Sleeping Arrangement) Bunk Beds
3.7 Adequacy of Living Space:
(x) Adequate
() Inadequate
3.8 Number of windows:
() None
() 1
() 2
(x) 3 or more
3.9 Food Storage:
() None
(x) Refrigerator
() Cabinet
() Others
3.10 Food Preparation
(x) Fried
(x) Boiled
() Others
3.11 ToiletType
() Pailsystem () OpenPitPrivy () ClosedPitPrivy () Bored HoleLatrine
()Antipolo type
() WaterSealedLatrine (x) FlushedType
3.12 Comfort Room Distance:
(x) inside
() Outside
if outside, how far? (In
meters) _________
3.13 Comfort Room Ownership:
(x) Owned
() Public
3.14 Sanitary Condition
(x) Good
() Poor
3.14 WaterSource
() Point source () Communal System/Stand Post
(x) Waterworks
system
3.15 Ownership of Water Supply
(x) Private
() Public
Remarks: (Pot ability) _______________________________
3.16 Method of Garbage Disposal
(x) Collected: (If yes: _x_ Government/ __ Private) () Burning ()
Composting () Segregation
() Hog Feeding
() Open dumping others:
___________
3.17 Animals Raised
(x) Dog
() Cat
() Pigs
() Chicken
(x)
others: ___Birds___
3.18 Immunization Status of Animal Raised
(x) Immunized
() Not Immunized
3.19 Backyard Gardening
() Herbal Plants () Vegetables
(x) Ornamental () Fruit Trees
3.20 Kind of Neighborhood
(x) Congested
() Slum
3. SOCIO-ECONOMIC AND CULTURAL VARIABLES
I.
SOCIAL INDICATORS
1. Source of Health Information: (x) Television () Mobile Phone () Radio () Poster () Health
Workers (x) Newspaper
Others: (specify):_____
Means of Transportation: (x) Jeepney () Bus Tricycle
() others (pls. specify): _____
2. Economic Indicators
2.1 Combined monthly income of the family members
() < 1000
() 1000-2999
() 3000-4999
() 7000-8999
above
3. Adequacy of income for family expenses (x) Yes
() No
4. Frequency of Meals
()1-2
() 3
(x) 3 or more
5. A. Percentage of expenditure
Chart
40%
Food
15% Water
30%
Electric
N/A Rentals
5%
Miscellaneous 5% Education
5%
Health
() 9000-10999
(x) 11000-
B.
Food
Electric
Education
Rentals
Water
Miscellaneous
6. Social Facilities: () Church (x) Wet And Dry Market () Day Care Center (x) Elementary School
(x) High School ( ) Park
() Sports Complex
(x) Health Center
() Senior Citizens Hall
() others
(Specify :) ___________
II.
CULTURAL FACTORS
1. Leadership styles of the officials
autocratic
participative
laissez faire leadership style
2. Health Beliefs Pertaining To Childcare, Sickness, Pregnancy, Postpartum Care, Newborn, Health
And Illness
They believe to not bathe the baby one week after delivery.
3. Concepts of Health and illness They believe it is contagious
4. Ways of Health Maintenance No fats, more vegetables
Health
5. Where do you consult when sick? (x) Health center
(x) Hospitals () Private clinic ()
Traditional Faith healer
6. Conditions that cause social issues/ conflicts Money problems
7. Practices/approaches that are effective in setting issues and concerns within the community:
democratic style of handling issues
8. Vices:
() smoking
(x) drinking () others
III.
OTHER INFORMATION RELATED TO FAMILY HEALTH
A. MATERNAL AND CHILD HEALTH (FOR PRENANT ONLY, LEAVE THIS PART IF FAMILY HAS NO
PREGNANT MEMBER)
1. PNCU
___ (+) PNCU ___ (-) PNCU Where: _______________
2. Reason for (-) PNCU
3. No. of Children born exactly 9 mos.
Immunization for TT
(+) ___ (-) ___ No. of doses received ______
4. Plan where to deliver ( )Health center ( ) home ( ) hospital ( ) lying in
5. Who assisted previous deliveries Nurse Midwife Hilot Doctor
6. Any history of pregnancy complications?
7. Myths and belief about child care
8. For children 0-2 years old ONLY
8.1 Type of infant feeding ( ) Breast feeding ( ) Mixed feeding ( ) Bottle feeding
8.2 Type of milk formula ( ) Condensed ( ) Evaporated ( ) Powdered
8.3 Food supplement given to babies ( ) Plain Lugaw ( ) Mashed Fruits and Vegetables ( ) Eggs,
Flakes meat, Fish
9. Immunization Status of 0-12 months only (leave if family has no 0-12 mos. old member)
BCG
Hepatitis B vaccine 1-3 OPV
DPT
Date Given: 5/30/2015
Where: OSMAK
Hep B 1 Date:
Where:
Hep B 2 Date:
Where:
Hep B 3 Date:
Where:
OPV 1 Date:
Where:
OPV 2 Date:
Where:
OPV 3 Date:
Where:
B. FAMILY PLANNING (REPRODUCTIVE AGE GROUP ONLY)
1. Acceptors ( )
Non Acceptors (x)
DPT 1 Date:
Where:
DPT 2 Date:
Where:
DPT 3 Date:
Where:
Attenuate
vaccine (
AMV 1 Da
Where:
2. Methods of family planning ( ) pills ( ) withdrawal ( ) rhythm ( ) condom ( ) IUD ( ) BTL ( ) Vasectomy
3. Reasons for Family planning: N/A
4. Reasons for Non-acceptors: Ready for pregnancy
C. CAUSES OF ILLNESS IN THE LAST SIX MONTHS
NAME
Vince Christian Labasa
Ryza Cassandra Yu
AGE
8
10
D. CAUSES OF DEATH IN THE LAST SIX MONTHS
NAME
E. CAUSES OF HOSPITIALIZATION IN THE LAST SIX MONTHS
NAME
FlorDeLiza Acua
Revised by CHN Team July 6, 2011
AGE
AGE
36
