SAINT LOUIS UNIVERSITYSchool of Nursing

FAMILY NURSING ASSESSMENT TOOL

Address of Family: _________________________________________________________

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

FAMILY NAME: _________________________________________ SURVEYED / DATA GATHERED BY: _________________________________INFORMANT: _________________________________________ DATE SURVEYED / GATHERED: _________________________________NAME OF HEALTH CENTER: __________________________________

A. FAMILY STRUCTURE, CHARACTERISTICS AND DYNAMICS/RELATIONAL PATTERNSFAMILY MEMBERS(include only those

living in the household. Start from the head

then immediate members then non-members living with

family as last)

RELATIONSHIP TO THE HEAD (head, wife of head, son,

daughter, mother/father/in-law, niece/nephew, cousin,

househelper, etc)

POSITION/ORDER IN THE FAMILY / OTHER ROLES

(Father & breadwinner, mother and store keeper, 1st child & cleaner, 2nd

child and cook, etc.)

BIRTHDATE(month & year)

AGE (should be

exact in years and in

months)

GENDER MARITAL STATUS PLACE OF RESIDENCE / WORK / STUDY (including non-emancipated working or

studying family members whether living with family or elsewhere)

DOMINANT DECISION MAKERS IN MATTERS OF:

(Please check appropriate column below)

HEALTH & CARE TENDING

MONEY & EXPENSES

TYPE OF FAMILY: 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; According to structure & composition: ________________________________ evidences of presence or absence of any obvious or readily observable conflict/s between members, etc.)According to family head and decision making: _________________________ Spouse subsystem: ___________________________________________________________________________________________________According to roles/bread-earning : ___________________________________ Parent-child subsystem: _______________________________________________________________________________________________________

Sibling-sibling subsystem: _____________________________________________________________________________________________________

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SAINT LOUIS UNIVERSITYSchool of Nursing

B. SOCIO-ECONOMIC AND CULTURAL CHARACTERISTICSFAMILY MEMBERS HIGHEST EDUCATIONAL

ATTAINMENT (last level completed at the time of survey &

none)

RELIGIOUS AFFILIATION ETHNIC BACKGROUND OCCUPATION INCOME (gathering this data requires non-leading & non-

embarassing questions)

OTHER SOURCES OF INCOME RELIGIOUS SECT WHERE

BAPTIZED WHAT RELIGIOUS SECT IS THE

MEMBER ACTIVE

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 Adequate (income=budget and actual expenses); inadequate (actual expenses exceeds budget and income); more than adequate (income exceeds actual expenses)Shelter (home maintenance/repairs, rent)

Clothing Education Health Electricity, electronics, communication and other servicesOthers (car repair/maintenance, gasoline, etc.)TOTAL

SIGNIFICANT OTHERS OF THE FAMILYNAME/S OF SIGNIFICANT MEMBERS PLACE OF RESIDENCE ROLES PLAYED IN THE FAMILY SUPPORT THAT THEY PROVIDE

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

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