ASSESSMENT DATA BASE IN FAMILY NURSING PRACTICE

X
ADDRESS: ________________________ X
__________________________ ______ X______ XXXXX
FAMILY NUMBER: _______________
Street / Road Barangay Zone

A. FAMILY STRUCTURE, CHARACTERISTICS, & DYNAMICS/RELATIONAL PATTERNS

1. Members of the Household
Birthdate Relationship to the Head of the
Name of Family Member Age Sex Civil Status Position in the Family
Month Year Family
Mohammad Isa J. Jalil 54 December 1965 M Married Father (head) Husband
Sauda A. Jalil 49 November 1970 F Married Mother Wife
Amna-Farah A. Jalil 19 June 2001 F Single Daughter (1st child) Daughter
Ahmad Rashad A. Jalil 13 October 2006 M Single Son (2nd child) Son

2. Socio-demographic data of members not currently living in the household but with major role in resource generation and use

Birthdate Highest Occupation

Name of Family Marital Relationship to Head of the
Age Sex Educational
Member Month Year Status Type of Work Place Family
Attainment

3. Length of residency:

21 years

4. Type of Family Structure and Form

 Based on Composition Based on Locus of Power Based on Place of Residency
Nuclear Family Stepfamily/Blended Patrifocal / Patriarchal Patrilocal

Extended Single Matrifocal / Matriarchal Matrilocal

Beanpole Same-sex/Homosexual Egalitarian Bilocal

Single-Parent Cohabiting/Communal Matricentric

5. Family Dynamics, Communication Pattern/s, Interaction Processes and Interpersonal Relationships.

Criteria Status Additional Information

Observable conflicts between family members

NONE There are no seen conflicts between the relationship of each individual
Characteristics of communication Verbal communication, even though the daughter studies in Zamboanga City they still
GOOD communicate through facebook
Interaction patterns among members
GOOD All members of the family are open to everyone and approachable.

B. SOCIO-ECONOMIC & CULTURAL CHARACTERISTICS

Highest Educational Occupation

Name of Family Member Ethnic Background Religion Income
Attainment Nature of Work Place of Work
Philippine National Tawi-Tawi Police
Mohammad Isa J. Jalil Tausug Islam College Graduate 10
Police Provincial Office
Sauda A. Jalil Tausug Islam College Graduate Housewife N/A N/A
Amna-Farah A. Jalil Tausug Islam 2nd Year College Student N/A N/A N/A
Ahmad Rashad A. Jalil Tausug Islam Grade 8 N/A N/A N/A
Legend for Monthly Family Income
1 – Below 2,500 3 – above 5,000 to 7,500 5 – above 10,000 to 12,500 7 – above 15,000 to 17,500 9 – above 20,000 to 25,000
2 – 2,500 to 5,000 4 – above 7,500 to 10,000 6 – above 12,500 to 15,000 8 – above 17,500 to 20,000 10 – above 25,000
1. Income & Expenses
a. Adequacy to Meet Basic Necessities
Income is adequate to meet basic necessities
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________

2. Family Traditions, events or practices affecting member’s health or family functioning

__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
____________________________

3. Significant Others – role(s) they play in family’s life

Name Role & Relation to Family

4. Relationship of the Family to Larger Community – Nature and extent of participation of the family in community activities
a. Awareness of existing organization Yes Name ________________________________ No
b. Membership in an organization Yes Name No No existing
Why? organizations in the community
_________________________
c. Involvement in an organization Yes Name ________________________________ No Why? _________________________
No existing organizations in the community
d. Potential or Existing leaders _None, because we do not have any membership in an organization.
____________________________________________________________________________________
C. HOME AND ENVIRONMENT
1. Home
Ownership: owned rented free Constructional material used: light mixed strong
Lighting facilities: electricity kerosene others (specify) ________________________
Number of rooms used for sleeping & sleeping arrangement: __________________________________________________________________________
3 rooms
2. Water Supply
Drinking: Source private public Potability: specify is safe for drinking Safe Unsafe
 Storage direct from faucet or pipe covered container with faucet large uncovered without faucet
Other (specify) __________________

3. Food storage
Cooking facility: electric gas stove firewood/charcoal
Sanitary condition: ___________________________________________________________________________________________________________
The sanitary condition is very good.
Drainage facility: open drainage blind drainage none
4. Water Disposal
a. Refuse and Garbage
 Container covered open none
 Method of disposal: hog feeding open dumping burial in pit composting open burning garbage collection
Other (specify) _________________________________________
b. Toilet
 Type: none overhung latrine open pit privy closed pit privy bored- hole latrine pail system
antipolo type water-sealed latrine flush type other (specify) _____________________________________________
 Distance from the house: ______________________________________
Five meters
 Sanitary Condition: ___________________________________________________________________________________________________
It is fairly clean and does not smell foul, they also have an open drainage.
5. Domestic Animals

Kind Number Where Kept

Cat 2 Cage

6. The Community in General

a. General sanitary condition: ___The general sanitary condition in our community is good with proper drainage system but there are some places in
the community, specifically the stilt houses along the shoreline that has contaminated and polluted waters due to improper waste
disposal._______________________________________________________________________________________________
_______________________________________________________
 b. Housing congestion: ______Houses in our subdivision have at least 3 meters of space from one house to another. But for the community in general,
there are houses outside or near the subdivision that is quite congested due to a large number of populations.
_________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________
c. Presence of breeding or resting sites of vectors of disease: ________________NONE_________________________________________________
_________________________

d. Recreational Facility: _________________NONE______________________________________________________________________________

e. Availability of health care services: _______________Only one available health care center_________________________
f. Distance of house from nearest health care facility: _____________About 100 meters away from our house_______________________
g. Communication & Transportation Facilities available: Cellphones for communication and motorcycle for transportation.

D. HEALTH STATUS OF EACH FAMILY MEMBER

1. Medical & Nursing History
a. Medical History of the Family Members

Family Member Health Status / Health History Family Member Health Status / Health History
Father Hypertension
Mother Neuropathy

b. Obstetric Data
Date BP PR Temp. Wt. H FH FHT
September 7, 130/90 72 beats/min, 36.5˚C 76kgs. 5’6”
2020
September 7, 130/80 78 beats/min. 37˚C 65kgs. 5’0”
2020
September 7, 110/70 80 beats/min. 37.5˚C 70kgs. 5’2”
2020
September 7, 120/70 70 beats/min. 37˚C 74kgs. 5’7”
2020
 2. Nutritional Assessment
a. Anthropometric Data: Measure of Nutritional Status of the Family Members

Name of Family Member Weight Height Mid-Arm Circumference

Mohammad Isa J. Jalil 76kgs. 5’6”
Sauda A. Jalil 65 kgs. 5’0”
Amna-Farah A. Jalil 70kgs. 5’2”
Ahmad Rashad A. Jalil 74kgs. 5’7”

b. Dietary History specifying quality & quantity of food/nutrient intake per day

_________________Less intake of sugar_____________________

c. Eating/Feeding habits/practices
__________3 meals per day_________________
3. Risk factor assessment indicating presence of major & contributing modifiable risk factors for specific lifestyle diseases ______________________________
_______________________________________________________________________________________________________________________________
4. Result of laboratory/diagnostic & other screening procedures supportive of assessment findings ________________________________________________
N/A

E. VALUES, HABITS, PRACTICES ON HEALTH PROMOTION, MAINTENANCE & DISEASE PREVENTION

1. Immunization status of family member

Name of Child Immunization Status Remarks

Amna-Farah A. Jalil Complete
Ahmad Rashad A. Jalil Complete

2. Healthy lifestyle practices ___________Getting enough sleep, eating healthy foods, physical activities_______________________
3. Adequacy of:
 a. Rest & Sleep Yes No
b. Exercise/Activities Yes specify: ___________________brisk walking for 30 mins. twice a week_________________________
c. Use of Protective Measures Yes _________________________________ No Why ___________________________________________
d. Relaxation & other stress management activities Yes _______________________________________ No
e. Opportunities which enhance feelings of self-worth, self-efficacy and sense of connectedness to self, others and a higher power, essence of
meaningfulness
Yes specify: _______________________________________________________________________ No
4. Use of promotive – preventive health services Yes specify: _________________________________________________________________________
No Why ________________________

5. Use of Family Planning Methods

a. Type
Natural
Abstinence Lactational Amenorrhea Method Basal Body Temperature Cervical Mucus Method
Symptothermal Method Standard Days Method Others: specify ___________________________________________

Artificial
Hormonal
Oral Contraceptives Specify: Progesterone – Only Oral Contraceptive Low- Dose Combined Oral Contraceptive
Injectable depot medroxyprogesterone acetate / Depo-Provera (DMPA)

Norplant Implants
Barrier
Intrauterine Devices Condom Diaphragm Cervical Cap Others: specify __________________________

Permanent

Tubal Ligation Vasectomy

None Are you willing to practice Family Planning Method? Yes No

What hinders you from practicing Family Planning Method? Biological Psychological Social Cultural
Religion Others, specify; _____________________
b. Who taught you about Family Planning Method?
PHN/PHM BHW Friend Neighbor Print/Visual Ads Student Nurse Others; specify ______________________
c. Is your husband aware of your usage of Family Planning Method Yes No
d. Do you know side effects of family planning method as a result of its use? Yes No
Changes in menstrual bleeding headache nausea weight gain moodiness
Delayed return of fertility dizziness acne in women nervousness change in appetite
Enlargement of ovaries/ovarian cyst hair loss breast tenderness others; specify _________________________________________
e. Do you have misconceptions about Family Planning Methods? Yes No
Some FP Methods cause abortion Using Contraceptives will render couples sterile Using contraceptives methods will result to loss sexual
desire
Others; specify _________________________________________________________________________