University of San Agustin
College of Health and Allied Medical Professions
Iloilo City
COMMUNITY HEALTH NURSING - INITIAL DATA BASE
Name of Interviewer: ________________________________________ Course & Year: ______________
C.I. Assigned: __________________________________________________________________________
Date Conducted: ___________________ Time Started: _______________ Time Ended: ______________
Name of Respondent (Optional) Position in the Family Age (18 & Above)
Zone / Sitio Barangay Municipality
I. Family Structure, Characteristics and Dynamics
A. Members of the Household
FAMILY MEMBER S BIRTHDATE OCCUPATION REMARKS/
No Name POSITION RELATION E MM Age MARITAL HIGHEST Type Monthly DATE
. IN THE TO HEAD X /DD STATUS EDUCATION of income ENTERED
FAMILY /YY COMPLETED work
1.
2.
3.
4.
5.
6.
7.
8.
B. Type of Family Structure Patriarchal Matriarchal Nuclear Extended Blended
C. Who are the dominant Family Members in terms of decision making?
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D. What is the general family relationship/dynamics? (Is there a presence of any obvious/readily
observable conflict between members; characteristics, communication/interaction patterns among
members?)
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University of San Agustin
College of Health and Allied Medical Professions
Iloilo City
II. Socio-Economic and Cultural Characteristics
A. Income and Expenses
o Occupation Unemployed Without permanent employment
With permanent employment
o Adequacy to meet basic needs. Able to buy food everyday Able to buy clothing
Able to buy materials for the house
o Who makes decisions about money and how it is spent?
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B. Religious Affiliation:
o Christian:
Roman Catholic Protestant Baptist Seventh Day Adventists
Iglesia ni Cristo Jehovah’s Witness Evangelical Christianity (Born Again)
Church of Jesus Christ of Latter-Day Saints (Mormon)
o Other major religions:
Islam (Muslim) Judaism Hinduism Buddhism Sikhism
Rizalista Pls. Specify: ___________________________
C. Family Traditions:
o What are the events or practice affecting members’ health or family function?
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D. Significant Others:
o Who are those non-family members that play a significant role in the life of the family?
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E. Relationship of the Family to the Larger Community:
o What is the nature and extent of participation of the family in community activities?
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III.
Home and Environment
1. Housing
o Ownership: Owned Rented Rent-Free
o Construction Materials used: Light Mixed Strong
o Number of rooms used for sleeping: _____________________________
o Lighting facilities: Electricity Kerosene
Others, specify: ___________________
University of San Agustin
College of Health and Allied Medical Professions
Iloilo City
a. How is the adequacy of living space?
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b. How is the family’s sleeping arrangement?
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c. Is there any presence of breeding or resting sites of vector of diseases (e.g. mosquitoes,
roaches, flies, rodents, etc.)
No Yes, where are they located?
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d. Is there a presence of accident hazard?
No Yes, where are they located?
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e. How is the food being stored and what are the different cooking facilities that they use?
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f. Water supply-source:
Private Public Main Source: ____________ Potability: _________________
g. Toilet Facilities:
o Type None Pail system Overhung Latrine Antipolo Type
Open Pit Privy Close Pit Privy Bored-hole Latrine
Flush Type Water-sealed Latrine
Others, specify: ______________________________
o Distance from the house:
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o Sanitary Condition:
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h. Garbage / Refuse Disposal:
o Container Type Covered Open None
o Method of Disposal Hog Feeding Open Burning Open Dumping
Burial in pit Composting
Garbage Collection
Others, specify: _______________________
o Sanitary Condition:
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i. Drainage System
o Type Open Drainage Blind Drainage None
o Sanitary Condition:
___________________________________________________________________
University of San Agustin
College of Health and Allied Medical Professions
Iloilo City
2. Kind of Neighborhood
a. Housing Congestion Yes No
b. General sanitary condition of the community:
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3. What are the Social facilities available in the area?
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4. What are the Health facilities available in the area?
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5. What are the means of communication available?
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6. What are the types of transportation facilities available?
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IV. Health Status of Each Family Member
A. Medical Nursing history indicating current or past significant illnesses or beliefs and practices
conducive to health and illness
FAMILY MEMBER Past Allergies Accidents / Hospitalization Medications
No Name Illnes Injuries (Reason/When (Drug/Dose/
. / Where) Frequency)
1.
2.
3.
4.
5.
6.
7.
8.
B. Nutritional Assessment
FAMILY MEMBER Anthropometric Data Dietary History Eating Habits/
Practices
No. Name Weight Height BMI Classification Medications
(kg) (cm)
1.
2.
3.
4.
5.
6.
7.
University of San Agustin
College of Health and Allied Medical Professions
Iloilo City
C. Developmental assessment of infant, toddlers and preschoolers.
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D. Risk factor assessment indicating presence of major and contributing modifiable risk factors for
specific lifestyle diseases.
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E. Physical Assessment indicating presence of illness state/s (diagnosed or undiagnosed by medical
practitioners)
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F. Results of laboratory/diagnostic and other screening procedures supportive of assessment
findings.
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V. Values, Habits, Practices on Health Promotion, Maintenance and Disease Prevention.
FAMILY MEMBER Immunizations / Vaccinations
No. Name BCG HEPA B DPT HIB OPV IPV PCV MMR HPV Influenza Varicella
1.
2.
3.
4.
5.
6.
7.
8.
University of San Agustin
College of Health and Allied Medical Professions
Iloilo City
FAMILY MEMBER Adequacy of:
No Name Healthy Rest Exercise/ Protective Relaxation &
. Lifestyle and Activities Measure Stress
Practices Sleep Management
1.
2.
3.
4.
5.
6.
7.
8.
A. What promotive-preventive health services do you avail in the Health Centers / your Community?
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