SAINT LOUIS UNIVERSITY

School of Nursing
FAMILY NURSING ASSESSMENT TOOL

Address of Family: _________Kawal Bokod Benguet _______________________

(House #, Purok or Zone, Street #, Barangay, Municipality, Province)

FAMILY NAME: _Catayaw________________________________ SURVEYED / DATA GATHERED BY: _________________________________

INFORMANT: _Lito Catayaw____________________________ DATE SURVEYED / GATHERED: _________________________________
NAME OF HEALTH CENTER: __________________________________

A. FAMILY STRUCTURE, CHARACTERISTICS AND DYNAMICS/RELATIONAL PATTERNS

FAMILY MEMBERS RELATIONSHIP TO THE HEAD POSITION/ORDER IN THE FAMILY / BIRTHDATE AGE GENDER MARITAL STATUS PLACE OF RESIDENCE / WORK / DOMINANT DECISION MAKERS IN
(include only those (head, wife of head, son, OTHER ROLES (month & year) (should be STUDY (including non- MATTERS OF:
living in the household. daughter, mother/father/in- (Father & breadwinner, mother and exact in years emancipated working or (Please check appropriate column
Start from the head law, niece/nephew, cousin, store keeper, 1st child & cleaner, 2nd and in studying family members below)
then immediate househelper, etc) child and cook, etc.) months) whether living with family or HEALTH & CARE MONEY &
members then non- elsewhere) TENDING EXPENSES
members living with
family as last)
Lito Catayaw Father January 5,1967 M M Bokod
Lucia Catayaw Wife mother January 18,1968 F M Bokod
Rosela Catayaw Son 1992 M M Bokod
Jeric Son 5 September 13,2004 M S
Michelle Daughter 6 February 4,2005 F S Pito Highschool
Melody Daughter 7 April 8,2006 F S Pito Highschool
Robin Daughter 9 February 16,2007 M S Pito Highschool
Crisanto Son 10 August 28,2008 M S
Nicole Daughter 11 March 19,2010 F S
son 12 August 19, 2012 M S

TYPE OF FAMILY:
According to structure & composition: __Extended______________________
According to family head and decision making: _shared___________________
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: _seldom discuss or talk about intimate topics_________________________________________________________________

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 SAINT LOUIS UNIVERSITY
School of Nursing

B. SOCIO-ECONOMIC AND CULTURAL CHARACTERISTICS

FAMILY MEMBERS HIGHEST EDUCATIONAL RELIGIOUS AFFILIATION ETHNIC BACKGROUND OCCUPATION INCOME (gathering this data OTHER SOURCES OF INCOME
ATTAINMENT (last level RELIGIOUS SECT WHERE WHAT RELIGIOUS SECT IS THE requires non-leading & non-
completed at the time of survey & BAPTIZED MEMBER ACTIVE embarassing questions)
none)
Lito Elementary Roman catholic Roman catholic Ilokano/ Ibaloy average net income of 10,000 Remittance sent by Nerio
Lucia Elementary Roman catholic Roman catholic Ilokano/ Ibaloy Farmer Per havrvest of 3 months =3000/month
Rosela Elementary Roman catholic Roman catholic Ilokano/ Ibaloy Farmer
Roman catholic Roman catholic Ilokano/ Ibaloy Carpenter
Roman catholic Roman catholic Ilokano/ Ibaloy Student
Michelle Grade 6 Roman catholic Roman catholic Ilokano/ Ibaloy Student
Melody Grade 5 Roman catholic Roman catholic Ilokano/ Ibaloy Student
Grade 4 Roman catholic Roman catholic Ilokano/ Ibaloy Student
Crisanto Grade 1 Roman catholic Roman catholic Ilokano/ Ibaloy Student
Nicole Kinder Roman catholic Roman catholic Ilokano/ Ibaloy Student

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 3000 3000 Adequate (income=budget and actual expenses); inadequate (actual expenses exceeds budget and income); more than
Shelter (home maintenance/repairs, rent) 500 0 adequate (income exceeds actual expenses)
Clothing 0 0 The appropriate income is 3000 2 000 sent byNerio = 5000, that actual expences/month is 9000 therefore there is a small
Education 500 600 amount with 1200/month, the income is adequate to provide some with the basic necessities with the family they can use
Health 0 0 this for clothing,
Electricity, electronics, communication and other services 500 300
Others (car repair/maintenance, gasoline, etc.) 500 0
TOTAL 6000/month 3900/motnh

SIGNIFICANT OTHERS OF THE FAMILY

NAME/S OF SIGNIFICANT MEMBERS PLACE OF RESIDENCE ROLES PLAYED IN THE FAMILY SUPPORT THAT THEY PROVIDE
Close relatives Financial and emotional support

neighbors Share vegetables and pyshiological supports

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

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