Family Nursing Assessment Tool tabulation:
Age:
1-10
11-20
21-30
31-40
41-50
51-60
61-70
71-80
81-90
Number of family members (add totals together)
Sex:
F
M
Civil status:
Married
Single
Common Law
Education:
College graduate
College (unfinished)
High School graduate
High School (unfinished)
Elementary graduate
Elementary (unfinished)
K1
K2
Nursery
System of authority:
Matriarchal
Patriarchal
Egalitarian
Type of Family:
Nuclear
Extended
Single parent
Cohabitation (living in couples)
Income bracket:
<5000
5000-10,000
10,000-15,000
15,000-20,000
>20,000
Owners of their lot:
Yes
No
Owners of their house:
Yes
No
Construction materials of house:
Mixed
Wood
Concrete
Adequate living space:
Yes
No
Type of garbage disposal:
Collected
Burned
Segregated
Buried
Fed to animals
Thrown in river
Open dumping
Type of waste disposal
Flush
Pit privy
Wrap and throw
Water-sealed
Type of drainage
Closed
Open
Type of water supply
Owned
Shared
Bought
Drinking water storage:
Open
Covered
Refrigerated
Container used:
Plastic pitchers
Bottles
Jars, Clay pots
Food storage/Cooking facilities:
Covered
Uncovered
Refrigerator
Cabinet
Stove
Rice cooker
Pets/animals:
Dogs
Cats
Chickens
Presence of insect breeding sites:
Yes
No
Presence of accident hazards:
Yes
No
Preferred health consultant:
Manghihilot
Midwife
Doctor
BHW
Albularyo
Nurse
Health center staff
Preferred consultant for non-health problems:
Family members
Relatives
Friends
Barangay Officials
Priest
Completed immunizations:
OPV
DPT
Measles
BCG
HepaB
TT
Past week experience of:
1.
Adequate rest and sleep
Yes
No
2.
Exercise
Yes
No
3.
Relaxation activities
Yes
No
4.
Stress management activities
Yes
No