Makati Medical Center College of Nursing

144 Legaspi Corner V.A. Rufino St., Libran House, Legazpi Village, Makati City

Family Database

Name of Interviewee: Flor De Liza J. Acuña Age: 36 y/o House #: 7157 Purok/Barangay: Pio Del PilarReligion: Catholic Place of Origin: Manila Length of Residency: 36 years Number of Family Members: 5

A. FAMILYDATA1. FAMILY MEMBERSNames Date of

BirthAge Sex Civil

StatusEducationAttainment

Occupation Income

Estelita Acuña (Mother) 09/03/1943 72 y/o Female M Grade 6 Level

Dressmaker P3,000

Dolce Acuña (Sister) 08/20/1975 39 y/o Female S Vocational Course

Call Center (Encoder)

P9,000

Vince Christian Labasa (Baby) 12/09/2006 8 y/o Male S Grade 3 Student -

Ryza Cassandra Yu (Baby) 06/14/2005 10 y/o Female S Grade 5 Student -

(Buie) Bienveniedo Acuña (Brother)

11/29/1973 40 y/o Male S College Level Collector of Payment

P10,000

Jezi Maey Acuña (Baby) 05/29/2015 1 mo. Female S - - -

1. FAMILY STRUCTURE AND CHARACTERISTICS2.1 Family Structure ( ) Nuclear ( ) Two career Single Parent ( ) Adolescent Family ( x) Blended ( ) Cohabiting ( ) Gay and lesbian ( ) Extended2.2 Base on Authority ( ) Patriarchal (x) Matriarchal ( ) Egalitarian ( ) Matricentric2.3 Stages of Family Relationships ( ) Beginning ( ) Child Bearing (x) Family with Preschoolers ( ) With School Age ( ) Teenagers & Young Adults ( ) Post Parental ( ) Aging 2.4 Dominant in Decision Making (x) Mother ( ) Father ( ) Both ( ) Others ___________2.5 General Family Relationships/Dynamics (x) Highly Favorable ( ) Moderately Favorable ( ) Unfavorable Remarks: (Describe briefly) _____2.6 Significant Others (Indicate roles they play in the family’s life) Jerry Yu (Husband)2.7 Relationship of the family to the larger Community (Describe the nature and extent of participation) When there are events they participate.

2.7.1 Activities Attended: (x) Barangay Assembly ( ) Clean-up Drives ( ) Health Teachings ( ) Seminars

2.7.2 Extent of Participation: (x) Always ( ) Most of the Time ( ) Sometimes ( ) Seldom ( ) Never

2. HomeandEnvironment3.1 ConstructionMaterialsused: () Strong (x) Light () Mixed () Makeshift

3.2 Home Ownership: (x) Owned () Rented () Rentfree3.3 LightingFacilities:

3.3.1 (x) Electricity () Kerosene Lamp

3.3.2 () Adequate () Inadequate

3.4 CookingFacility: (X) Electricstove () Gasstove () Kerosene () firewood/charcoal 3.4.1 Sanitary Condition () Good () Poor

3.5 DrainageFacility: () None () Opendrainage (x) Blinddrainage () Others: 3.6 Numberofbedrooms: () None () 1 (x) 2 () 3 or more Remarks: (Describe the Family’s Sleeping Arrangement) Bunk Beds

3.7 Adequacy of Living Space: (x) Adequate () Inadequate 3.8 Number of windows: () None () 1 () 2 (x) 3 or more 3.9 Food Storage: () None (x) Refrigerator () Cabinet () Others 3.10 Food Preparation (x) Fried (x) Boiled () Others 3.11 ToiletType () Pailsystem () OpenPitPrivy () ClosedPitPrivy () Bored HoleLatrine

()Antipolo type () WaterSealedLatrine (x) FlushedType 3.12 Comfort Room Distance: (x) inside () Outside if outside, how far? (In meters) _________ 3.13 Comfort Room Ownership: (x) Owned () Public 3.14 Sanitary Condition (x) Good () Poor 3.14 WaterSource () Point source () Communal System/Stand Post (x) Waterworks system 3.15 Ownership of Water Supply (x) Private () Public

Remarks: (Pot ability) _______________________________ 3.16 Method of Garbage Disposal (x) Collected: (If yes: _x_ Government/ __ Private) () Burning () Composting () Segregation

() Hog Feeding () Open dumping others: ___________ 3.17 Animals Raised (x) Dog () Cat () Pigs () Chicken (x) others: ___Birds___ 3.18 Immunization Status of Animal Raised (x) Immunized () Not Immunized 3.19 Backyard Gardening () Herbal Plants () Vegetables (x) Ornamental () Fruit Trees 3.20 Kind of Neighborhood (x) Congested () Slum

3. SOCIO-ECONOMIC AND CULTURAL VARIABLESI. SOCIAL INDICATORS

1. Source of Health Information: (x) Television () Mobile Phone () Radio () Poster () Health Workers (x) Newspaper Others: (specify):_____ Means of Transportation: (x) Jeepney () Bus Tricycle () others (pls. specify): _____

2. Economic Indicators

2.1 Combined monthly income of the family members () < 1000 () 1000-2999 () 3000-4999 () 7000-8999 () 9000-10999 (x) 11000-above

3. Adequacy of income for family expenses (x) Yes () No4. Frequency of Meals ()1-2 () 3 (x) 3 or more

5. A. Percentage of expenditure B. Chart

40% Food 15% Water30% Electric N/A Rentals5% Miscellaneous 5% Education5% Health

6. Social Facilities: () Church (x) Wet And Dry Market () Day Care Center (x) Elementary School (x) High School ( ) Park () Sports Complex (x) Health Center () Senior Citizen’s Hall () others (Specify :) ___________

II. CULTURAL FACTORS1. Leadership styles of the officials autocratic participative laissez faire leadership

style2. Health Beliefs Pertaining To Childcare, Sickness, Pregnancy, Postpartum Care, Newborn, Health

And Illness

Food Electric Water Miscellaneous Health

Education Rentals

They believe to not bathe the baby one week after delivery.3. Concepts of Health and illness They believe it is contagious4. Ways of Health Maintenance No fats, more vegetables5. Where do you consult when sick? (x) Health center (x) Hospitals () Private clinic ()

Traditional Faith healer6. Conditions that cause social issues/ conflicts Money problems7. Practices/approaches that are effective in setting issues and concerns within the community:

democratic style of handling issues8. Vices: () smoking (x) drinking () others

III. OTHER INFORMATION RELATED TO FAMILY HEALTHA. MATERNAL AND CHILD HEALTH (FOR PRENANT ONLY, LEAVE THIS PART IF FAMILY HAS NO

PREGNANT MEMBER)1. PNCU ___ (+) PNCU ___ (-) PNCU Where: _______________ 2. Reason for (-) PNCU3. No. of Children born exactly 9 mos.

Immunization for TT (+) ___ (-) ___ No. of doses received ______ 4. Plan where to deliver ( )Health center ( ) home ( ) hospital ( ) lying in5. Who assisted previous deliveries Nurse Midwife Hilot Doctor6. Any history of pregnancy complications? 7. Myths and belief about child care8. For children 0-2 years old ONLY

8.1 Type of infant feeding ( ) Breast feeding ( ) Mixed feeding ( ) Bottle feeding8.2 Type of milk formula ( ) Condensed ( ) Evaporated ( ) Powdered8.3 Food supplement given to babies’ ( ) Plain Lugaw ( ) Mashed Fruits and Vegetables ( ) Eggs, Flakes meat, Fish

9. Immunization Status of 0-12 months only (leave if family has no 0-12 mos. old member)BCG Hepatitis B

vaccine 1-3OPV DPT Attenuated

measles vaccine (AMV)

Remarks

Date Given: 5/30/2015

Hep B 1 Date: OPV 1 Date: DPT 1 Date: AMV 1 Date:

Where: OSMAK

Where:Hep B 2 Date: Where:Hep B 3 Date: Where:

Where:OPV 2 Date: Where:OPV 3 Date: Where:

Where:DPT 2 Date: Where:DPT 3 Date: Where:

Where:

B. FAMILY PLANNING (REPRODUCTIVE AGE GROUP ONLY)1. Acceptors ( ) Non Acceptors (x)2. Methods of family planning ( ) pills ( ) withdrawal ( ) rhythm ( ) condom ( ) IUD ( ) BTL ( ) Vasectomy3. Reasons for Family planning: N/A4. Reasons for Non-acceptors: Ready for pregnancy

C. CAUSES OF ILLNESS IN THE LAST SIX MONTHSNAME AGE CAUSE OF SICKNESS

Vince Christian Labasa 8 Fever & DiarrheaRyza Cassandra Yu 10 Fever & Diarrhea

D. CAUSES OF DEATH IN THE LAST SIX MONTHS

NAME AGE CAUSE OF SICKNESS

E. CAUSES OF HOSPITIALIZATION IN THE LAST SIX MONTHSNAME AGE CAUSE OF SICKNESS

FlorDeLiza Acuña 36 Delivery

Revised by CHN Team July 6, 2011