INTERVIEWS Merged

COLLEGE OF NURSING
CARLATAN, SAN FERNANDO CITY, LA UNION
FAMILY ASSESSMENT GUIDE

COMMUNITY NEEDS ASSESSMENT /MINIMUM BASIC NEEDS (MBN) FOMR
Date: January 05, 2024
Family Name: Corpuz / Pagdildilan (Barangay)
I. Demographic Data
Household Number: 0015 Barangay House Number: 37
II. FAMILY DATA
Length of Residency: 13 years Place of origin: Tubao
Family Size: 3 Religion: Roman Catholic
Husband: Randel L. Corpuz
Wife: Angellie L. Corpuz
FAMILY MEMBER’S CHART
FAMILY MEMBERS AGE SEX CIVIL POSITION IN RELATIONSH OCCUPATION

THE FAMILY IP TO THE EDUCATIONAL
STATUS
FAMILY ATTAINMENT
HEAD
1.Angelie L. Corpuz 38 F Married Mother Husband High School None
Graduate
2.Randel L. Corpuz 45 M Married Father Head 2nd year Tricycle
High School Driver
3. Susana L. Corpuz 76 W Widowed Mother-in- Son-in- Grade 6 Farmer
law law
III. FAMILY CHARACTERISTICS
Type of Family Structure

A. Extended: ____ B. Matriarchal: _____ C. Dominant Family Member: ___
D. Nuclear: ✔ E. Patriarchal: _____
General Family Relationship/Dynamics

CRITERIA STATUS ADDITIONAL
INFORMATION
Observable conflicts between family Miscommunication N/A
members
Characteristics of communication Verbal N/A
Interaction patterns among members Sitting around the N/A
table, or through
gadgets
Family Dietary Habits

A. What did you eat yesterday? (24 hours dietary recall)
Breakfast: Pancit Canton with Rice
Lunch: Paksiw na bulilit with Rice
Dinner/Supper: Fried na bulilit with Rice
B. Monthly Family Income Source
Husband: 2,500-3,000 Wife: None
Others: ________________________________________________________________
below Ph 5,000 ✔ above PhP 20,000- 30,000 __________

above Ph 5,000-10,000____ above PhP 30,000- 40,000___________
above Ph 10,000- 15,000___ above Ph 40,000- 50000 ____________
above Ph 15,000-20,000____ above Ph 50,000
FAMILY HEALTH STATUS/HEALTH HISTORY

Father: Hypertension
Mother: Ovarian Cyst
Children/s: Wellness/Healthy
FELT FAMILY NEEDS (Identify and rank according to priority)

1. Food 5. Internet Connection
2. Water 6.
3. Appliances 7.
4. Gadgets 8.
IV. HOME AND ENVIRONMENT
A. Is your lot owned? YES ✔ NO_________________
B. Is your house owned? YES ✔ NO_________________
C. Type of Housing materials? wood ____________ concrete: ✔
Mixed: ______ makeshift: _____ others, specify__________________________
D. Is the living space adequate? YES ✔ NO____________________
E. What are the appliances owned by the family? Television, Radio, Cellphones, Electric
Fan
F. Type of Garbage Disposal
__________Collected ✔ burning
__________Waste segregation ✔ burying
__________ feeding animals __________ throw in the river
✔ open dumping _________ others, specify _____
G. Type of waste Disposal
__________Flush ✔ water-sealed (private)
__________wrap and throw __________ pit-privy
__________dig and bury _________water-sealed (communal)
Others,specify: None________________________________________
H. Types of Drainage System ✔ Open ____________ Closed
I. Source of water ✔ owned ✔ bought __________shared
Others, specify_________________________________________________________
J. Drinking water storage
____________ refrigerated ✔ Covered Uncovered: ____________________
K. Container used
✔ Plastic pitchers _____________jars /clay pots
✔ bottles _____________others,specify
L. Food Storage/ Cooking facilities
✔ Covered ______________Uncovered ___________Stove
Refrigerator ✔ Cabinet ✔ Pots/pans
M. Common Household pests found at home
1.Ants 2. Mosquito 3. Cockroach
N. Are there breeding sites of insects, rodents present? YES ✔ NO________
O. Pet/ Animals kept in the home/Yard Dogs, Chicken
P. Are there hazards present? YES ✔ NO________________________
V. HEALTH and HEALTH PRACTICES

A. Common illnesses encountered for the last 6 months and treatment applied
____________ diarrhea _______ colds _____________cough
____________influenza_______stomach pains_______headache
______/______toothache___/___Hypertension________Diabetes
____________gastritis ________ __________________others, specify
B. Whom do you consult for health-related problems?
___________” Manghihilot “ __________midwife
_____/______Doctor __________BHW
___________quack doctor/ albularyo __________Clinic
___________self-medication others, specify___________________________
C. For problems other than health, whom do you consult?
_____/______ family members ____________relatives
___________friends __________barangay officials
___________priest Others, specify ______________________________
D. Immunization status of family members
E. Have you had adequate?
_____1. Rest YES ✔ NO______
_____2. Exercises YES____ NO ✔
_____3. Relaxation Activities YES ✔ NO______
_____4. Stress management YES ✔ NO______
VI. KIND OF NEIGHBOORHOOD

1. Kind of Neighborhood Relative
2. Social and Health facilities Health Center, Basketball court,
available
3. Communication and Tricycle, Gadgets; Verbal
transportation
V. AWARENESS OF COMMUNITY ORGANIZATION

A. Are you aware of the existing organizations in the community? YES ✔ NO_________
B. Name all the organizations you know? Tupad, Senior Citizen, 4p’s
C. Are you member of these organizations? YES ✔ NO_____________
D. Are you aware of its activities and projects? YES ✔ NO_____________
E. How are you involved in its activities?
✔ 1. Attend meeting _______4. Give donations
_______2. Planning _______5. Evaluation
_______3. Implementation others, specify_____________________
F. Name five (5) formal and non-formal leaders of the community whom you think can lead the
people?
POSITION
1. Jun M. Balcita Mayor
2. Arturo P. Valdriz Captain
3. Leydene Bermudez BHW
4. Jamir Cabanban Kagawad
5. Rose Ann Singh Kagawad
Interviewer: Julie Anne Mae P. Acosta

Student Nurse II Section: Travelbee
Clinical Instructor: Michelle Sandoval & Ma. Lourdes Inaldo

COLLEGE OF NURSING

I. Demographic Data
Household Number: N/A Barangay House Number: N/A
II. FAMILY DATA
Length of Residency: 47 years Place of origin: Pagdildilan
Husband: Rodel Corpuz
Wife: Glenda Corpuz
FAMILY MEMBERS AGE SEX CIVIL POSITION IN RELATIONSHIP OCCUPATION

THE FAMILY TO THE EDUCATIONAL
STATUS
FAMILY ATTAINMENT
HEAD
1.Rodel Corpuz 47 M Married Father Head High Farmer/
School Tricycle
Graduate driver
2.Glenda Corpuz 46 F Married Mother Wife High Housewife
School
Graduate
3. Sherill Corpuz 13 F Single Daughter Father HS Student
Student
4.RJ Rodel Corpuz 18 M Single Son Father HS Student
Student

B. Extended: ____ B. Matriarchal: _____ C. Dominant Family Member: ___

INFORMATION
Observable conflicts between family None N/A
members
Characteristics of communication Verbal, Gadgets N/A
Interaction patterns among members At meal time N/A

What did you eat yesterday? (24 hours dietary recall)
Breakfast: Dinengdeng na utong with Rice
Lunch: Dinengdeng na utong with Rice
Dinner/Supper: Sinigang na bangus with Rice
Monthly Family Income Source

Husband: 5,000 Wife: None
Others: ________________________________________________________________

above Ph 10,000- 15,000___ above Ph 40,000- 50000 ____________
above Ph 15,000-20,000____ above Ph 50,000

Father: None
Mother: None
Children/s: None

1. Money 5.
2. Water 6.
3. Food 7.
4. Gadgets 8.
C. Type of Housing materials? wood ____________ concrete: _____________
Mixed: ✔ makeshift: _____ others, specify__________________________
E. What are the appliances owned by the family? Iron, Electric Fan, Radio
G. _____/_____Collected __________ burning
__________Waste segregation ____/______ burying
__________ open dumping _________ others, specify _____
H. Type of waste Disposal
__________Flush _____/_____ water-sealed (private)
I. Types of Drainage System _____/_____ Open ____________ Closed
J. Source of water ________ owned __________ bought _____/_____shared
Others, specify:
K. Drinking water storage
____________ refrigerated ______/_____ Covered Uncovered: ____________________
L. Container used
_______/_____ Plastic pitchers _____________jars /clay pots
____________ bottles _____________others,specify
M. Food Storage/ Cooking facilities
_______/_____ Covered ______________Uncovered ___________Stove
__________Refrigerator ______________Cabinet ______________ Pots/pans
N. Common Household pests found at home
1.Mouse 2. N/A 3. __________
O. Are there breeding sites of insects, rodents present? YES ✔ NO________
P. Pet/ Animals kept in the home/Yard Cow
Q. Are there hazards present? YES ____________ NO ✔
HEALTH and HEALTH PRACTICES
____________toothache______Hypertension________Diabetes
____________gastritis None others, specify
_____/______” Manghihilot “ __________midwife
___________Doctor _____/_____BHW
_____/______quack doctor/ albularyo _____/_____Clinic
_____/______ family members _______/_____relatives
_____/______friends ______/____barangay officials
_____1. Rest YES ✔ NO______
_____2. Exercises YES_______ NO ✔
F. KIND OF NEIGHBOORHOOD
1.Kind of Neighborhood Relative
2.Social and Health facilities available Health Center, Basketball court,
3.Communication and transportation Tricycle, Verbal

B. Name all the organizations you know? Farmer’s Organization
✔ 1. Attend meeting ✔ 4. Give donations
✔ 2. Planning ✔ 5. Evaluation
✔ 3. Implementation others, specify_____________________
people?
POSITION
3. Leydin Bermudez BHW
4. Raffy Marzan Kagawad
Interviewer: Vladimir C. Otanes

COLLEGE OF NURSING

Family Name: Guray / Pagdildilan (Barangay)
G. Demographic Data
Household Number: N/A Barangay House Number: 60
H. FAMILY DATA
Husband: Ruben Guray
Wife: Catalina Guray

STATUS
FAMILY ATTAINMENT
HEAD
1.Ruben Guray 83 M Married Father Head Vocational
2.Catalina Guray 71 F Married Mother Wife Undergra-
duate
I. FAMILY CHARACTERISTICS

C. Extended: ____ B. Matriarchal: _____ C. Dominant Family Member: ___

INFORMATION
Observable conflicts between family Minor conflicts N/A
members
Interaction patterns among members Parties, Date, N/A
Church

Breakfast: Dinengdeng with Rice
Lunch: Dinengdeng and Prinitong bangus with Rice
Dinner/Supper: Balatung and Prinitong bangus with Rice
Others: ________________________________________________________________

above Ph 10,000- 15,000___ above Ph 40,000- 50000 ____________
above Ph 15,000-20,000____ above Ph 50,000

Father: COPD (smoker) Hypertension (130/80)
Mother: None
Children/s: None

1. Money 5.
2. Water 6.
3. Food 7.
4. Road 8.
HOME AND ENVIRONMENT
s your house owned? YES ✔ NO_________________
B. Type of Housing materials? wood ____________ concrete: ✔
Mixed: _____________ makeshift: _____ others, specify__________________________
Is the living space adequate? YES ✔ NO____________________
C. What are the appliances owned by the family? Iron, Electric Fan, Radio
D. Type of Garbage Disposal
__________Collected __________ burning
__________Waste segregation __________ burying
__________ open dumping ___/_____ others, specify pit
E. Type of waste Disposal
_____/_____Flush __________ water-sealed (private)
F. Types of Drainage System __________ Open ______/______ Closed
G. Source of water ____/____ owned __________ bought __________shared
Others, specify:
K. Container used
____________ bottles _______jug___others,specify
____________ Covered ______________Uncovered ___________Stove
_____/____Refrigerator ______________Cabinet ______________ Pots/pans
1.Rat _________ 2. Termites 3. __________
O. Pet/ Animals kept in the home/Yard Chicken, Dog, Cat
P. Are there hazards present? ✔ YES NO ____________
H. HEALTH and HEALTH PRACTICES
____________ diarrhea ___/____ colds ______/______cough
____________toothache___/___Hypertension________Diabetes
___________Doctor _____/_____BHW
___________quack doctor/ albularyo _____/_____Clinic
_____/______self-medication others, specify___________________________
___________friends ______/____barangay officials
_____1. Rest YES ✔ NO______
_____2. Exercises YES ✔ NO ______
D. Kind of Neighborhood Relative
E. Social and Health facilities Barangay clinic,
available
F. Communication and Walking, Verbal and Gadgets
transportation

✔ 1. Attend meeting ____________ 4. Give donations
__________ 2. Planning ____________5. Evaluation
__________ 3. Implementation ____________others, specify_________
people?
POSITION

COLLEGE OF NURSING

Family Name: Viluan / Pagdildilan (Barangay)
I. Demographic Data
II. FAMILY DATA
Length of Residency: 6 months Place of origin: Pagdildilan
Husband:
Wife:

STATUS
FAMILY ATTAINMENT
HEAD
1.Onofre Viluan 45 M Separated Father Head Vocational Farmer
2. Grace Viluan 84 F Married Grand- Mother High Housewife
mother School
Graduate
3. Russel Kyle 38 M Single Nephew Uncle College Call
Sahidsahid Graduate Center

G. Extended: / B. Matriarchal: _____ C. Dominant Family Member: ___
D. Nuclear: ____ E. Patriarchal: _____

INFORMATION
Observable conflicts between family Separation by N/A
members Family (Ongoing)
Interaction patterns among members At mealtime N/A

Breakfast: Puto and Bread
Lunch: Nilagang pork adobo with Rice
Others: ________________________________________________________________

above Ph 10,000- 15,000___ above Ph 40,000- 50000 ____________
above Ph 15,000-20,000____ above Ph 50,000

Father: None
Mother: None
Children/s: None

1. Money 5.
2. Water 6.
3. Food 7.
4. 8.
IV. Is your lot owned? YES ✔ NO_________________
V. Type of Housing materials? wood ____________ concrete: ✔
VI. What are the appliances owned by the family? Washing Machine, Electric Fan,
Radio, Aircon
VII. Type of Garbage Disposal
_____/_____Collected __________ burning
__________Waste segregation _____/_____ burying
_____/_____ feeding animals __________ throw in the river
__________ open dumping __________ others, specify pit
VIII. Type of waste Disposal
IX. Types of Drainage System _____/_____ Open ___________ Closed
X. Source of water ________ owned _____/_____ bought __________shared
Others, specify:
G. Drinking water storage
______/______ refrigerated __________ Covered Uncovered: ____________________
H. Container used
_______/_____ bottles _____________others,specify
I. Food Storage/ Cooking facilities
J. Common Household pests found at home
1. Ants 2. Mosquitos 3. __________
K. Are there breeding sites of insects, rodents present? YES ✔ NO________
L. Pet/ Animals kept in the home/Yard Cats and Dogs
M. Are there hazards present? ✔ YES NO ____________
XI. HEALTH and HEALTH PRACTICES
N. Common illnesses encountered for the last 6 months and treatment applied
______/______ diarrhea _______ colds ____________cough
____________influenza_______stomach pains____/___headache
____________gastritis others, specify __Jaundice_____
O. Whom do you consult for health-related problems?
_____/______Doctor __________BHW
P. For problems other than health, whom do you consult?
___________ family members _______/_____relatives
_____/______priest Others, specify ______________________________
Q. Immunization status of family members
R. Have you had adequate?
_____1. Rest YES ✔ NO______
_____3. Relaxation Activities YES _________ NO ✔
XII. KIND OF NEIGHBOORHOOD

H. Kind of Neighborhood Relative
I. Social and Health facilities Barangay Hall
available
J. Communication and Motor, Verbal
transportation

B. Name all the organizations you know? Senior Citizen
C. Are you member of these organizations? YES _____________ NO ✔
__________ 1. Attend meeting ✔. Give donations
people?
POSITION


COLLEGE OF NURSING

S. Demographic Data
T. FAMILY DATA
Wife: Glenda Corpuz

STATUS
FAMILY ATTAINMENT
HEAD
School Tricycle
Graduate driver
School
Graduate
3. Sherill Corpuz 13 F Single Daughter Father HS Student
Student
4.RJ Rodel Corpuz 18 M Single Son Father HS Student
Student
U. FAMILY CHARACTERISTICS

K. Extended: ____ B. Matriarchal: _____ C. Dominant Family Member: ___

INFORMATION
members

Others: ________________________________________________________________

above Ph 10,000- 15,000___ above Ph 40,000- 50000 ____________
above Ph 15,000-20,000____ above Ph 50,000

Father: None
Mother: None
Children/s: None

1. Money 5.
2. Water 6.
3. Food 7.
4. Gadgets 8.
V. HOME AND ENVIRONMENT
C. Type of Housing materials? wood ____________ concrete: _____________
E. What are the appliances owned by the family? Iron, Electric Fan, Radio
G. _____/_____Collected __________ burning
H. Type of waste Disposal
I. Types of Drainage System _____/_____ Open ____________ Closed
J. Source of water ________ owned __________ bought _____/_____shared
Others, specify:
K. Drinking water storage
L. Container used
M. Food Storage/ Cooking facilities
N. Common Household pests found at home
1.Mouse 2. N/A 3. __________
O. Are there breeding sites of insects, rodents present? YES ✔ NO________
P. Pet/ Animals kept in the home/Yard Cow
Q. Are there hazards present? YES ____________ NO ✔
HEALTH and HEALTH PRACTICES
___________Doctor _____/_____BHW
_____1. Rest YES ✔ NO______
L. Kind of Neighborhood Relative
M. Social and Health facilities Health Center, Basketball court,
available
N. Communication and Tricycle, Verbal
transportation

people?
POSITION

COLLEGE OF NURSING

I. Demographic Data
II. FAMILY DATA
Husband: Jose V.Copuz
Wife:
FAMILY MEMBERS AGE SEX CIVIL POSITION IN RELATIONSHIP OCCUPATIO

THE FAMILY TO THE EDUCATIONAL N
STATUS
FAMILY ATTAINMENT
HEAD
1.Rodel Corpuz 61 M Separated Father Head Elementary Farmer
graduate

O. Extended: ____ B. Matriarchal: _____ C. Dominant Family Member: ___

INFORMATION
members
Characteristics of communication Gadgets N/A
Interaction patterns among members None N/A

Breakfast: Adobong Manok, rice and milk
Lunch: Dinengdeng nga rabong with rice
Dinner/Supper: Intuno nga tilapia with rice

Others: ________________________________________________________________

above Ph 10,000- 15,000___ above Ph 40,000- 50000 ____________
above Ph 15,000-20,000____ above Ph 50,000

Father: None
Mother: None
Children/s: None

1. 5.
2. 6.
3. 7.
4. 8.
Is your lot owned? YES ✔ NO_________________
Is your house owned? YES ✔ NO_________________
Type of Housing materials? wood ____________ concrete: _____________
What are the appliances owned by the family? Cellphone, Electric Fan, Radio, TV,
Type of Garbage Disposal
______/____ open dumping _________ others, specify _____
Type of waste Disposal

Types of Drainage System _____/_____ Open ____________ Closed

Source of water ____/____ owned __________ bought __________shared
Others, specify:
Drinking water storage

Container used
Food Storage/ Cooking facilities

V. Common Household pests found at home

1.Cockroach 2. Mosquito 3. __________
Are there breeding sites of insects, rodents present? YES ✔ NO________

Pet/ Animals kept in the home/Yard Dogs, Pigs, Cow
Are there hazards present? ✔ YES NO________
IV. HEALTH and HEALTH PRACTICES
Common illnesses encountered for the last 6 months and treatment applied
____________ diarrhea ____/___ colds _______/______cough
Whom do you consult for health-related problems?
___________Doctor _____/_____BHW
For problems other than health, whom do you consult?
___________ family members ____________relatives
Immunization status of family members
Have you had adequate?
_____1. Rest YES ✔ NO______
_____2. Exercises YES ✔ NO
V. KIND OF NEIGHBOORHOOD
P. Kind of Neighborhood Relative
Q. Social and Health facilities Health Center, Basketball court
available
R. Communication and Tricycle, Verbal
transportation

B. Name all the organizations you know?
2. Planning 5. Evaluation
3. Implementation others, specify_____________________
people?
POSITION
3. Leydin Bermudez BHW

COLLEGE OF NURSING

Family Name: Subido/ Pagdildilan (Barangay)
I. Demographic Data
II. FAMILY DATA
Length of Residency: 86 years Place of origin: Pagdildilan, San Juan
Husband: Marcelo Subido Wife: Clarita Subido
FAMILY MEMBERS AGE SEX CIVIL POSITIO RELATIONSH OCCUPATION

EDUCATIONAL
STATUS N IN THE IP TO THE
ATTAINMENT
FAMILY FAMILY
HEAD
1. Clarita Subido 86 F Widowed Mother Head Elementary None
Graduate
2.Silverio Subido 56 M Single Son Mother Highschool None
Graduate


INFORMATION
members
Communication
Interaction patterns among members Verbal N/A
Communication

Breakfast: Milk with rice
Lunch: Petchay and Tomato Salad
Dinner/Supper: Milk
Husband: None Wife: None
Others: ________________________________________________________________
below Ph 5,000_____ above PhP 20,000- 30,000 __________

above Ph 10,000- 15,000___ above Ph 40,000- 50000 ____________
above Ph 15,000-20,000____ above Ph 50,000

Father: N/A
Mother: Wellness/Healthy
Children/s: PWD

1. Money 5.
2. Food 6.
3. Water 7.
4. 8.

C. Type of Housing materials? wood ____________ concrete: ___________
Mixed: ______ makeshift: ✔ others, specify__________________________
D. Is the living space adequate? YES✔ NO____________________

E. What are the appliances owned by the family? None

__________ feeding animals __________throw in the river
__________open dumping __________ others, specify _____
Others,specify_____________________________________________________
I. Source of water ✔ owned _______________bought __________shared

Others, specify_________________________________________________________
___________refrigerated ✔ Covered Uncovered: ____________________
K. Container used
____________bottles _____________others,specify
___________Refrigerator ______________Cabinet __________Pots/pans
1. Mosquito 2. Termites 3. Cockroach
N. Are there breeding sites of insects, rodents present? YES______________NO✔
O. Pet/ Animals kept in the home/Yard Cat

____________ diarrhea _______ colds ✔ cough
✔ toothache______Hypertension________Diabetes
___________Doctor __________BHW
___________self-medication others, specify None
✔ family members ✔ relatives
D. Immunization status of family members: Fully Vaccinated
_____1. Rest YES✔ NO______
_____2. Exercises YES✔ NO______
_____3. Relaxation Activities YES✔ NO______
_____4. Stress management YES✔ NO______

2. Social and Health facilities School, Church, Barangay Healthy
available Center, Barangay Hall
3. Communication and Verbal Communication
transportation

A. Are you aware of the existing organizations in the community? YES______ NO✔
B. Name all the organizations you know? None
C. Are you member of these organizations? YES_______ NO ✔
D. Are you aware of its activities and projects? YES_____ NO ✔

No 1. Attend meeting No 4. Give donations
No 2. Planning No 5. Evaluation
No 3. Implementation others, specify_____________________
people?
POSITION
1. Jun Balcita Captain
2. Paul Navarro Kagawad
3. Rose Ann Signh Kagawad
4. Debelyn Fernandez Kagawad
5. Jamer Cabanban Kagawad
Interviewer: Irezze Christelle Carig and Vladimir Otanes

Clinical Instructor: Ma. Lourdes Inaldo and Michelle Sandoval

COLLEGE OF NURSING

Family Name: Dela Cruz/ Pagdildilan Barangay)
I. Demographic Data
Household Number: 77 Barangay House Number: N/A
II. FAMILY DATA
Length of Residency: 5 years Place of origin: Pagdildilan, San Juan
Husband: Santos Dela Cruz Wife: Lucresia Dela Cruz
FAMILY MEMBERS AGE SE CIVIL POSITION IN RELATIONSHI OCCUPATION

EDUCATIONAL
STATUS THE FAMILY P TO THE
X FAMILY ATTAINMENT
HEAD
1. Santos L. Dela Cruz 55 M Married Father Head Elementa Farmer
ry
Graduate
2. Lucresia Dela Cruz 65 F Married Mother Husband Highscho Farmer
ol
Graduate
3.Sammy Dela Cruz 35 M Single Son Father Vocation Farmer
al
4.Clynton Clarence Dela 13 M Single Grandson Grandfath Student Student
Cruz er
5.Carl Clarence 11 M Single Grandson Grandfath Student Student
Ranches er
6. Lorena Ranches 36 F Single Daughter Father Highscho Farmer
ol
Graduate

A. Extended: ✔ B. Matriarchal: _____ C. Dominant Family Member: ___
D. Nuclear: _____ E. Patriarchal: _____

INFORMATION
members
Characteristics of communication Good N/A
Communication
Interaction patterns among members Keep in touch with N/A
each other

Breakfast: Coffee, Rice, Pork Adobo
Lunch: String beans Dinengdeng
Dinner/Supper: Snail

Husband: None Wife: None
Others: None

above Ph 10,000- 15,000___ above Ph 40,000- 50000 ____________
above Ph 15,000-20,000____ above Ph 50,000

Father: Gallstones
Mother: Migraine

1. Financial 5.
2. Mediations 6.
3. 7.
4. 8.
A. Is your lot owned? YES __________ NO ✔
Mixed: ______ makeshift: ✔ others, specify__________________________
D. Is the living space adequate? YES_____________NO ✔

E. What are the appliances owned by the family? None
__________Collected __________burning
Others,specify_____________________________________________________
I. Source of water ___________owned ✔ bought __________shared

Others, specify_________________________________________________________
___________refrigerated ✔ Covered Uncovered: ____________________
K. Container used
1. Mosquito 2. Fly 3. ___________________
O. Pet/ Animals kept in the home/Yard Dogs, Ducks, Chicken, Fish

____________ diarrhea ✔ colds ✔ cough
____________influenza_______stomach pains ✔ headache
____________toothache ✔ Hypertension________Diabetes
✔ Doctor ✔ BHW
✔ self-medication others, specify___________________________
✔ family members ____________relatives
_____1. Rest YES ✔ NO______
_____2. Exercises YES ✔ NO______

2. Social and Health facilities School, Church, Barangay Health
3. Communication and Tricycle, Verbal Communication
transportation

A. Are you aware of the existing organizations in the community? YES______ NO ✔
B. Name all the organizations you know? None
C. Are you member of these organizations? YES_______ NO ✔
D. Are you aware of its activities and projects? YES_____ NO ✔
people?
POSITION
1. Roseann Singh Kagawad
2. Raffy Marsan Kagawad
4. Jeysa Bermudez Kagawad
Interviewer: Irezze Christelle Carig and Vladimir Otanes

Clinical Instructor: Ma. Lourdes Inaldo and Michelle Sandoval

COLLEGE OF NURSING

Family Name: Subido / Pagdildilan (Barangay)
I. Demographic Data
II. FAMILY DATA
Length of Residency: 15 years Place of origin: San Juan, La Union
Family Size: __5 Religion: Roman Catholic
Husband : Jessie C. Subido, Sr.
Wife : Jaynalyn B. Subido
FAMILY MEMBERS AG SE CIVIL POSITIO RELATIONSH OCCUPATION

EDUCATIONAL
STATUS N IN THE IP TO THE
E X FAMILY FAMILY
ATTAINMENT
HEAD
1. Jaynalyn B. Subido 34 F Married Mother Husband Highschool Housewife
Graduate
2.Jessie C. Subido, Sr. 50 M Married Father Head Highschool Farmer
Graduate
3. Justin Dave B. Subido 18 M Single Son Father Student Student
4. Jan Isaac B. Subido 16 M Single Son Father Student Student
5. Jessie B. Subido, Jr. 10 M Single Son Father Student Student


INFORMATION
members
Characteristics of communication Chitchats, Good N/A
communication,
Good listener
Interaction patterns among members They keep in touch N/A
with each other

Breakfast: Egg with Rice
Lunch: Sinigang na Baboy
Dinner/Supper: Adobong Paa ng Manok

Others: ________________________________________________________________

above Ph 10,000- 15,000___ above Ph 40,000- 50000 ____________
above Ph 15,000-20,000____ above Ph 50,000

Father: Wellness/ Healthy
Mother: Wellness/ Healthy
Children/s: Wellness/ Healthy

1. Money 5. Success
2. Peace 6. Food
3. Spiritual 7. Lose Weight
4. Wellness 8. Abundance
B. Is your house owned? YES✔ NO_________________
D. Is the living space adequate? YES✔ NO____________________
E. What are the appliances owned by the family? Television, Refrigerator, Washing
Machine
✔ Waste segregation ✔ burying
Others,specify_____________________________________________________
I. Source of water _____✔______owned _______✔________bought
__________shared
Others, specify_________________________________________________________
_____✔______refrigerated _________Covered Uncovered:
____________________
K. Container used
______✔______Plastic pitchers _____________jars /clay pots
______✔______bottles _____________others,specify
_____✔______Covered ______________Uncovered ___________Stove
_____✔_____Refrigerator ______________Cabinet __________Pots/pans
1. Fly 2. Mosquito 3. Cockroach
N. Are there breeding sites of insects, rodents present? YES__________NO___✔_____
O. Pet/ Animals kept in the home/Yard Dog, Cat, Cow, Carabao
P. Are there hazards present? YES _____✔_________ NO____________________

____________ diarrhea ____✔___ colds ______✔_______cough
_____✔___ Doctor _____✔__ BHW
_____✔__ family members ____________relatives
_____1. Rest YES ✔ NO______

3. Communication and Cellphone, Motorcycle
transportation

A. Are you aware of the existing organizations in the community? YES___✔__ NO_________
C. Are you member of these organizations? YES_______ NO_____✔________
D. Are you aware of its activities and projects? YES___✔__ NO_____________
✔1. Attend meeting _______4. Give donations
✔2. Planning ✔5. Evaluation
✔3. Implementation others, specify_____________________
people?
POSITION
Interviewer: Irezze Christelle P. Carig


COLLEGE OF NURSING

Family Name: Peralta/Pagdildilan(Barangay)
I. Demographic Data
II. FAMILY DATA
Length of Residency: 10 years Place of origin: San Juan, La Union
Family Size:4 Religion: Roman Catholic
Husband: Reynold Peralta Wife: Joy Sobrepeña
FAMILY MEMBERS AGE SE CIVIL POSITION RELATIONSHI OCCUPATION

EDUCATIONAL
STATUS IN THE P TO THE
X FAMILY FAMILY ATTAINMENT
HEAD
1. Reynald B. Peralta 32 M Live in Father Head College Hog Raiser
Gradate
2. Joy F. Sobrepeña 32 F Live in Mother Husband College Pharmacy
Graduate Assistant
3. Reynz S. Peralta 10 M Single Son Father Student Student
4. Dlanyer S. Peralta 8 M Single Son Father Student Student

D. Nuclear: ✔E. Patriarchal: _____

INFORMATION
members
Characteristics of communication Good N/A
Communication
Interaction patterns among members Keep in touch with N/A
each other

Breakfast: Fried egg and tapa
Lunch: Pakbet
Dinner/Supper: Pakbet and sinigang na baboy

Husband: 5,000 Wife: 10,000
Others: ________________________________________________________________

above Ph 5,000-10,000 ✔ above PhP 30,000- 40,000___________
above Ph 10,000- 15,000___ above Ph 40,000- 50000 ____________
above Ph 15,000-20,000____ above Ph 50,000

Father: Wellness/Healthy
Mother: Wellness/Healthy
Children/s: Asthma

1. Money 5. Spiritual
2. Moral Support 6. Own Shelter
3. Food 7.
4. Water 8.
B. Is your house owned? YES___________ NO ✔
D. Is the living space adequate? YES ✔NO____________________
E. What are the appliances owned by the family? Refrigerator and Television
__________Collected ✔burning
__________Waste segregation ✔burying
✔open dumping __________ others, specify _____
__________Flush ✔water-sealed (private)
Others,specify_____________________________________________________
H. Types of Drainage System ✔Open ____________ Closed
I. Source of water ✔ owned ✔bought __________shared
Others, specify_________________________________________________________
✔refrigerated _________Covered Uncovered: ____________________
K. Container used
✔Plastic pitchers _____________jars /clay pots
✔bottles _____________others,specify
✔Covered ______________Uncovered ___________Stove
✔Refrigerator ______________Cabinet __________Pots/pans
1. Fly 2. Mosquito 3. Cockroach
N. Are there breeding sites of insects, rodents present? YES______________NO✔
O. Pet/ Animals kept in the home/Yard Dog, Chicken, Pig
P. Are there hazards present? YES ✔NO________________________

____________ diarrhea ✔colds ✔cough
____________influenza_______stomach pains✔headache
✔toothache______Hypertension________Diabetes
✔Doctor BHW
___________self-medication others, specify Wife
✔family members ____________relatives
_____1. Rest YES✔ NO______

3. Communication and Cellphone, Motorcycle
transportation

A. Are you aware of the existing organizations in the community? YES✔NO_________
C. Are you member of these organizations? YES_______ NO✔
D. Are you aware of its activities and projects? YES✔NO_____________
people?
POSITION
Interviewer: Irezze Christelle P. Carig


COLLEGE OF NURSING

I. Demographic Data
II. FAMILY DATA
Length of Residency: 13 years Place of origin: Tubao
Husband: Randel L. Corpuz
Wife: Angellie L. Corpuz
FAMILY MEMBERS AGE SE CIVIL STATUS POSITION IN RELATIONSH OCCUPATION

THE FAMILY IP TO THE EDUCATIONAL
X FAMILY ATTAINMENT
HEAD
1.Angelie L. Corpuz 38 F Married Daughter- Husband High School None
in-law Graduate
2.Randel L. Corpuz 45 M Married Son Head Elementary Tricycle
Driver
3. Susana L. Corpuz 76 F Widowed Mother-in- Son Elementary Farmer
law


INFORMATION
Observable conflicts between family Miscommunication N/A
members
Interaction patterns among members Sitting around the N/A
table, or through
gadgets

Breakfast: Pancit Canton with Rice
Lunch: Paksiw na bulilit with Rice
Dinner/Supper: Fried na bulilit with Rice
Others: ________________________________________________________________

above Ph 10,000- 15,000___ above Ph 40,000- 50000 ____________
above Ph 15,000-20,000____ above Ph 50,000

Father: Hypertension
Mother: Ovarian Cyst

1. Food 5. Internet Connection
2. Water 6.
3. Appliances 7.
4. Gadgets 8.
E. What are the appliances owned by the family? Television, Radio, Cellphones, Electric
Fan
✔ open dumping _________ others, specify _____
I. Source of water ✔ owned ✔ bought __________shared
Others, specify_________________________________________________________
____________ refrigerated ✔ Covered Uncovered: ____________________
K. Container used
✔ bottles _____________others,specify
Refrigerator ✔ Cabinet ✔ Pots/pans
1.Ants 2. Mosquito 3. Cockroach
O. Pet/ Animals kept in the home/Yard Dogs, Chicken

______/______toothache___/___Hypertension________Diabetes
_____/______Doctor __________BHW
_____1. Rest YES ✔ NO______
_____2. Exercises YES____ NO ✔

available
3. Communication and Tricycle, Gadgets; Verbal
transportation

B. Name all the organizations you know? Tupad, Senior Citizen, 4p’s
✔ 1. Attend meeting _______4. Give donations
people?
POSITION
5. Rose Ann Singh Kagawad


COLLEGE OF NURSING

I. Demographic Data
II. FAMILY DATA
Wife: Glenda Corpuz

STATUS
FAMILY ATTAINMENT
HEAD
School Tricycle
Graduate driver
School
Graduate
3. Sherydel Corpuz 13 F Single Daughter Father Elementar Student
y
4.RJ Rodel Corpuz 18 M Single Son Father Elementar Student
y

B. Extended: ____ B. Matriarchal: _____ C. Dominant Family Member: ___

INFORMATION
members

Dinner/Supper: Sinigang 6ab angus with Rice

Others: ________________________________________________________________

above Ph 10,000- 15,000___ above Ph 40,000- 50000 ____________
above Ph 15,000-20,000____ above Ph 50,000

Father: None
Mother: None
Children/s: None

1. Money 5.
2. Water 6.
3. Food 7.
4. Gadgets 8.
Q. Is your lot owned? YES ✔ NO_________________
R. Is your house owned? YES ✔ NO_________________
S. Type of Housing materials? Wood ____________ concrete: _____________
T. Is the living space adequate? YES ✔ NO____________________
U. What are the appliances owned by the family? Iron, Electric Fan, Radio
V. Type of Garbage Disposal
W. _____/_____Collected __________ burning
X. Type of waste Disposal
Y. Types of Drainage System _____/_____ Open ____________ Closed
Z. Source of water ________ owned __________ bought _____/_____shared
Others, specify:
A. Drinking water storage
B. Container used
C. Food Storage/ Cooking facilities
D. Common Household pests found at home
1.Mouse 2. N/A 3. __________
E. Are there breeding sites of insects, rodents present? YES ✔ NO________
F. Pet/ Animals kept in the home/Yard Cow
G. Are there hazards present? YES ____________ NO ✔
F. Common illnesses encountered for the last 6 months and treatment applied
G. Whom do you consult for health-related problems?
___________Doctor _____/_____BHW
H. For problems other than health, whom do you consult?
I. Immunization status of family members
J. Have you had adequate?
_____1. Rest YES ✔ NO______

available
6. Communication and Tricycle, Verbal
transportation

people?
POSITION
COLLEGE OF NURSING

Family Name: Guray / Pagdildilan (Barangay)
I. Demographic Data
Household Number: N/A Barangay House Number: 60
II. FAMILY DATA
Husband: Ruben Guray
Wife: Catalina Guray

STATUS
FAMILY ATTAINMENT
HEAD
1.Ruben Guray 83 M Married Father Head Vocational
2.Cahthalina Guray 71 F Married Mother Wife Undergra-
duate

C. Extended: ____ B. Matriarchal: _____ C. Dominant Family Member: ___

INFORMATION
Observable conflicts between family Minor conflicts N/A
members
Interaction patterns among members Parties, Date, N/A
Church

Breakfast: Dinengdeng with Rice
Lunch: Dinengdeng and Prinitong bangus with Rice
Dinner/Supper: Balatung and Prinitong bangus with Rice

Others: ________________________________________________________________

above Ph 10,000- 15,000___ above Ph 40,000- 50000 ____________
above Ph 15,000-20,000____ above Ph 50,000

Father: COPD (smoker) Hypertension (130/80)
Mother: None
Children/s: None

1. Money 5.
2. Water 6.
3. Food 7.
4. Road 8.
B. Type of Housing materials? wood ____________ concrete: ✔
C. What are the appliances owned by the family? Iron, Electric Fan, Radio
D. Type of Garbage Disposal
__________ open dumping ___/_____ others, specify pit
E. Type of waste Disposal
F. Types of Drainage System __________ Open ______/______ Closed
G. Source of water ____/____ owned __________ bought __________shared
Others, specify:
IV. Drinking water storage
V. Container used
____________ bottles _______jug___others,specify
VI. Food Storage/ Cooking facilities
VII. Common Household pests found at home
1.Rat _________ 2. Termites 3. __________
VIII. Are there breeding sites of insects, rodents present? YES ✔ NO________
IX. Pet/ Animals kept in the home/Yard Chicken, Dog, Cat
X. Are there hazards present? ✔ YES NO ____________
H. HEALTH and HEALTH PRACTICES
K. Common illnesses encountered for the last 6 months and treatment applied
____________ diarrhea ___/____ colds ______/______cough
L. Whom do you consult for health-related problems?
___________Doctor _____/_____BHW
___________quack doctor/ albularyo _____/_____Clinic
_____/______self-medication others, specify___________________________
M. For problems other than health, whom do you consult?
N. Immunization status of family members
O. Have you had adequate?
_____1. Rest YES ✔ NO______
I. KIND OF NEIGHBOORHOOD
8. Social and Health facilities Barangay clinic,
available
9. Communication and Walking, Verbal and Gadgets
transportation

✔ 1. Attend meeting ____________ 4. Give donations
people?
POSITION


COLLEGE OF NURSING

Family Name: Viluan / Pagdildilan (Barangay)
I. Demographic Data
II. FAMILY DATA
Length of Residency: 6 months Place of origin: Pagdildilan
Husband:
Wife:

STATUS
FAMILY ATTAINMENT
HEAD
1.Onofre Viluan 45 M Separated Father Head Vocational Farmer
2. Grace Viluan 82 F Married Grand- Mother High Housewife
mother School
Graduate
3. Russel Kyle 28 M Single Nephew Uncle College Call
Sahidsahid Graduate Center
Agent

D. Extended: / B. Matriarchal: _____ C. Dominant Family Member: ___
D. Nuclear: ____ E. Patriarchal: _____

INFORMATION
Observable conflicts between family Separation by N/A
members Family (Ongoing)
Interaction patterns among members At mealtime N/A

Breakfast: Puto and Bread
Lunch: Nilagang pork adobo with Rice
Others: ________________________________________________________________

above Ph 10,000- 15,000___ above Ph 40,000- 50000 ____________
above Ph 15,000-20,000____ above Ph 50,000

Father: None
Mother: None
Children/s: None

1. Money 5.
2. Water 6.
3. Food 7.
4. 8.
IV. Is your lot owned? YES ✔ NO_________________
V. Type of Housing materials? wood ____________ concrete: ✔
VI. What are the appliances owned by the family? Washing Machine, Electric Fan,
Radio, Aircon
VII. Type of Garbage Disposal
_____/_____Collected __________ burning
__________Waste segregation _____/_____ burying
_____/_____ feeding animals __________ throw in the river
__________ open dumping __________ others, specify pit
VIII. Type of waste Disposal
IX. Types of Drainage System _____/_____ Open ___________ Closed
X. Source of water ________ owned _____/_____ bought __________shared
Others, specify:
XI. Drinking water storage
______/______ refrigerated __________ Covered Uncovered: ____________________
XII. Container used
_______/_____ bottles _____________others,specify
XIII. Food Storage/ Cooking facilities
XIV. Common Household pests found at home
1. Ants 2. Mosquitos 3. __________
XV. Are there breeding sites of insects, rodents present? YES ✔ NO________
XVI. Pet/ Animals kept in the home/Yard Cats and Dogs
XVII. Are there hazards present? ✔ YES NO ____________
XI. HEALTH and HEALTH PRACTICES
P. Common illnesses encountered for the last 6 months and treatment applied
______/______ diarrhea _______ colds ____________cough
____________influenza_______stomach pains____/___headache
____________gastritis others, specify __Jaundice_____
Q. Whom do you consult for health-related problems?
_____/______Doctor __________BHW
R. For problems other than health, whom do you consult?
___________ family members _______/_____relatives
_____/______priest Others, specify ______________________________
S. Immunization status of family members
T. Have you had adequate?
_____1. Rest YES ✔ NO______
_____3. Relaxation Activities YES _________ NO ✔
XII. KIND OF NEIGHBOORHOOD

11. Social and Health facilities Barangay Hall
available
12. Communication and Motor, Verbal
transportation

B. Name all the organizations you know? Senior Citizen
C. Are you member of these organizations? YES _____________ NO ✔
__________ 1. Attend meeting ✔. Give donations
people?
POSITION


COLLEGE OF NURSING
FAMILY ASSESSMENT GUIDE COMMUNITY NEEDS ASSESSMENT /MINIMUM

BASIC NEEDS (MBN) FOMR
Date: January 6 2024
Family Name: CORPUZ /PAGDILDILAN (Barangay)
I. Demographic Data
Household Number: 0016 Barangay House Number: N/A II.
FAMILY DATA
Family Size:6 Religion: Roman Catholic Husband: Rufino B. Corpuz wife:
Merisa B. Corpuz

FAMILY MEMBERS AGE SE CIVIL POSITION RELATIONSHIP EDUCATIONAL OCCUPATIO
IN THE TO THE FAMILY N
X STATUS FAMILY ATTAINMENT
HEAD
1.Rufino B. Corpuz 57 M Married Head Elementary FARMER

Graduate
2.Merisa B. Corpuz 52 F Married Mother Wife High School MAID
Graduate
3.Jaybee B. Corpuz 29 M Married Son Father College Electrical
Graduate Engineer
4.Jenifer B. Corpuz 27 F Single Daughter Father College Electronics
Graduate
5.Honey Mae B. Corpuz 24 F Single Daughter Father College Food
Graduate Technologist
6.Vincent B. Corpuz 15 M Single Son Father High School Student
7.
8.
9.
10.

A. Extended: ____ B. Matriarchal: _____ C. Dominant Family Member: ___ D.
Nuclear: __/___ E. Patriarchal: _____
INFORMATION
Observable conflicts between family None None

members
Characteristics of communication Verbal None
Interaction patterns among members Quality time None

Breakfast: Lechon paksiw with rice
Lunch: Lechon paksiw with rice
Dinner/Supper: Graham with water

Husband: 4000-5000 Wife: ______________________________
Others: ________________________________________________________________
below Ph 5,000__/___ above PhP 20,000- 30,000 __________

above Ph 5,000-10,000____ above PhP 30,000- 40,000___________ above
Ph 10,000- 15,000___ above Ph 40,000- 50000 ____________
above Ph 15,000-20,000____ above Ph 50,000

Father: Wellness/ Healthy
Mother: Wellness/ Healthy
Children/s: Wellness/ Healthy

1. Internet Connection 5. Water pump
2. Grocery 6.
3. Laptop 7.
4. Generator 8. IV.
A. Is your lot owned? YES ____/______ NO_________________
B. Is your house owned? YES____/_______ NO_________________
C. Type of Housing materials? wood ____________ concrete: ____/_______ Mixed:
______ makeshift: _____ others, specify__________________________
D. Is the living space adequate? YES_____/________NO____________________
E. What are the appliances owned by the family? Refrigerator, TV, Electricfan, Radio, Speaker
____/______Collected ____/______burning
____/______Waste segregation _____/_____burying
Others,specify: NONE
H. Types of Drainage System _____/_____Open ____________ Closed
I. Source of water _____/______owned ______/_________bought __________shared Others,
specify: NONE
_____/_____refrigerated _________Covered Uncovered: ____________________
K. Container used
_____/_______Plastic pitchers _____________jars /clay pots
_____/_______bottles _____________others,specify
___________Covered ______________Uncovered ___________Stove
1.Mosquito 2. _____________________ 3. ___________________
N. Are there breeding sites of insects, rodents present?
YES______________NO__/______
O. Pet/ Animals kept in the home/Yard Dog, Cow, Chicken, Pig
P. Are there hazards present? YES ________________ NO__/_____

_____/_______ diarrhea _______ colds _______/______cough
____________influenza___/____stomach pains___/____headache
___________Doctor __________BHW
_____/______self-medication others, specify___________________________ C.
______/_____ family members ____________relatives
priest Others, specify D.
Immunization status of family members Vaccinated
_____1. Rest YES__/__ NO______
_____2. Exercises YES__/__ NO______
_____3. Relaxation Activities YES__/__ NO______
_____4. Stress management YES__/__ NO______

2. Social and Health facilities Health Center, Church, School
available
3. Communication and transportation Tricycle, Jeep

A. Are you aware of the existing organizations in the community? YES___/___ NO_________
B. Name all the organizations you know? 4ps, Tupad
C. Are you member of these organizations? YES___/____ NO_____________ D. Are you aware of its
activities and projects? YES__/___ NO_____________
____/___1. Attend meeting ___/____4. Give donations
F. Name five (5) formal and non-formal leaders of the community whom you think can lead the people?
POSITION
1.RK SK Chairman
2.Rufino Corpuz KAPITAN
3.Honey Mae Corpuz KAGAWAD
4.______________________________________ _______________________
5.______________________________________ _______________________
Interviewer: Jameca H. Manzano

Clinical Instructor: Ma. Lourdes Inaldo & Michelle Sandoval
COLLEGE OF NURSING
FAMILY ASSESSMENT GUIDE COMMUNITY NEEDS ASSESSMENT /MINIMUM BASIC

NEEDS (MBN) FOMR
Date: January 5 , 2024
Family Name: Perez / Pagdildilan (Barangay)
I. Demographic Data
II. FAMILY DATA
Length of Residency: 72 years Place of origin: Padildilan
Family Size: 6 Religion: Roman Catholic Husband :_________ wife Norma S. Perez

FAMILY MEMBERS AGE SE CIVIL POSITION RELATIONSHIP OCCUPATION
STATUS IN THE TO THE FAMILY EDUCATIONAL
X FAMILY HEAD
ATTAINMENT
1.Norma S. Perez 72 F Widowe Head Undergrad None
d
2. Rose N. Terado 26 F Married Mother Aunt Undergrad None
3. Esteve Jhon C. Terado 30 M Married Father Aunt Undergrad None

4. Johanna Rose N. Terado 5 F Single Daughte Grand mother Kinder Merchandiser
r
5. Rey Jhon N. Terado 4 M Single Son Grand mother
6. Stecy N. Terado 1 F Single Daughte Grand mother
r
7.
8.
9.
10.

A. Extended: __/__ B. Matriarchal: _____ C. Dominant Family Member: ___ D.
Nuclear: _____ E. Patriarchal: _____

INFORMATION
Observable conflicts between family Resolved Miscommunication
members
Interaction patterns among members Quality time with None
children

Breakfast: Pizza
Lunch: Fried egg with rice
Dinner/Supper: Dinengdeng with bangus

Husband: 12,000- 13, 000 Wife: ______________________________
Others: ________________________________________________________________

above Ph 10,000- 15,000_/__ above Ph 40,000- 50000 ____________ above
Ph 15,000-20,000____ above Ph 50,000

Father: Asthma, Cough
Mother: None
Children/s: Asthma, Cough

1. Gadgets 5.
2. Internet Connection 6.
3. Insufficient Food and Water 7.
4. Household Appliances 8.
A. Is your lot owned? YES ____/______ NO_________________ B.
Is your house owned? YES_____/______ NO_________________
C. Type of Housing materials? wood ____________ concrete: ___________ Mixed:
__/____ makeshift: _____ others, specify__________________________
D. Is the living space adequate? YES_____/________NO____________________
E. What are the appliances owned by the family? Refrigerator, Television, Cellphone,
____/______Collected _____/_____burning
_____/_____Waste segregation _____/____burying
_____/_____open dumping __________ others, specify _____
Others,specify_____________________________________________________
H. Types of Drainage System __________Open _____/_______ Closed
I. Source of water ___________owned _______/________bought __________shared
Others, specify_________________________________________________________
_____/______refrigerated ___/______Covered Uncovered:
____________________
K. Container used
______/______Plastic pitchers _____________jars /clay pots
______/_____Refrigerator ______________Cabinet _____/_____Pots/pans
1. Mosquito 2. Cockroach 3. ___________________ N.
Are there breeding sites of insects, rodents present?
YES____/__________NO________
O. Pet/ Animals kept in the home/Yard 2 Cat, Chicken
P. Are there hazards present? YES ______/__________ NO________________________

____________ diarrhea _______ colds ________/_____cough
____________influenza___/____stomach pains__/_____headache
______/_____Doctor __________BHW
___________self-medication others, specify___________________________ C.
___________priest Others, specify ______________________________ D.
Immunization status of family members Vaccinated
_____1. Rest YES_/___ NO______
_____2. Exercises YES_/___ NO______
_____3. Relaxation Activities YES_/___ NO______
_____4. Stress management YES_/___ NO______

2. Social and Health facilities Health Center, Basketball Court, Church
available
3. Communication and transportation Tricycle, Gadgets, Verbal

A. Are you aware of the existing organizations in the community? YES___/___ NO_________
B. Name all the organizations you know? Tupad, Senior Citizen, 4ps
C. Are you member of these organizations? YES___/____ NO_____________ D. Are you aware of its
activities and projects? YES__/___ NO_____________ E. How are you involved in its activities?
____/___1. Attend meeting __/____4. Give donations
F. Name five (5) formal and non-formal leaders of the community whom you think can lead the people?
POSITION
1.Raffy Marjan Kagawad
2.Rose Ann Singh Kagawad
3.Laydel Bermode BNS
4.Jun Balcita Kapitan
5.Develyn Fernandez _Kagawad
Interviewer: Jameca H. Manzano


COLLEGE OF NURSING
FAMILY ASSESSMENT GUIDE COMMUNITY NEEDS ASSESSMENT /MINIMUM

BASIC NEEDS (MBN) FOMR Date: January 5, 2024
Family Name: Ramos / Pagdildilan (Barangay)
I. Demographic Data
II. FAMILY DATA
Length of Residency: 45 years Place of origin: Quezon City, Manila
Family Size: 6 Religion: Roman Caholic Husband :_________ wife : Aurora
B. Ramos

FAMILY MEMBERS AGE SE CIVIL POSITION RELATIONSHIP OCCUPATION
STATUS IN THE TO THE FAMILY EDUCATIONAL
X FAMILY HEAD
ATTAINMENT
1. Aurora B. Ramos 73 F Widowe Head High Farmer
d School
Graduate
2. Roberto Jr. Ramos 49 M MARRIE Son Mother High Tricycle
D School Driver
Graduate
3. Lovelyn Ramos 41 F MARRIE Mother Mother in law Elementary Maid
D in law Graduate
4. Jericho Ramos 16 M SINGLE Son Mother Student Student
5. Angelina Ramos 15 F SINGLE Daughte Mother Student Student
-r
6.
7.
8.
9.
10.

A. Extended: _/___ B. Matriarchal: _____ C. Dominant Family Member: ___
D. Nuclear: _____ E. Patriarchal: _____

INFORMATION
Observable conflicts between family Miscommunication None
members
Interaction patterns among members Quality time with None
children

Breakfast: Coffee & Bread
Lunch: Fried Fish & Dinengdeng with Rice
Dinner/Supper: Pancit

Husband: ___________________________ Wife: ______________________________
Others :Son 5,000-10,000
below Ph 5,000_____ above PhP 20,000- 30,000 __________ above
Ph 5,000-10,000_/___ above PhP 30,000- 40,000___________ above Ph
10,000- 15,000___ above Ph 40,000- 50000 ____________ above Ph
15,000-20,000____ above Ph 50,000

Father: Wellness & Healthy
Mother: Sakit sa Puso
Children/s: Wellness & Healthy

1. Food and water 5. 2.
Household appliances 6.
3. Gadgets 7.
4. Money 8.
A. Is your lot owned? YES ____/______ NO_________________
B. Is your house owned? YES____/_______ NO_________________
C. Type of Housing materials? wood ____________ concrete: _____/______ Mixed:
______ makeshift: _____ others, specify__________________________
D. Is the living space adequate? YES______/_______NO____________________
E. What are the appliances owned by the family? Refrigerator, Cellphone, Television,
OvenType of Garbage Disposal
____/______Collected _____/_____burning
_____/_____Waste segregation _____/_____burying
F. Type of waste Disposal
____/______Flush __________ water-sealed (private)
__________dig and bury _________water-sealed (communal) Others,specify None
G. Types of Drainage System __________Open ______/______ Closed
H. Source of water _____/______owned _______________bought __________shared
Others, specify_________________________________________________________
I. Drinking water storage
_____/______refrigerated _________Covered Uncovered:
____________________
J. Container used
_____/_______Plastic pitchers _____________jars /clay pots
_____/_______bottles _____________others,specify
K. Food Storage/ Cooking facilities
______/_____Refrigerator ______________Cabinet __________Pots/pans
L. Common Household pests found at home
1.________________________2. _____________________ 3. ___________________
M. Are there breeding sites of insects, rodents present?
YES_____/_________NO________
N. Pet/ Animals kept in the home/Yard Dog, Cat, Chicken, Pig
O. Are there hazards present? YES ________________ NO__________/______________

____________ diarrhea _______ colds ______/_______cough
____________gastritis ________ __________________others, specify B.
Whom do you consult for health-related problems?
_____/______Doctor __________BHW
_____/______ family members ______/______relatives
_____1. Rest YES_/___ NO______
_____2. Exercises YES_/___ NO______
_____3. Relaxation Activities YES_/___ NO______
_____4. Stress management YES_/___ NO______

2. Social and Health facilities Health Center, Basketball Court, Church
available
3. Communication and transportation Tricycle

A. Are you aware of the existing organizations in the community? YES__/____ NO_________
B. Name all the organizations you know? 4ps, Indigent, Tupad, Senior Citizen
C. Are you member of these organizations? YES___/____ NO_____________ D. Are you
aware of its activities and projects? YES__/___ NO_____________
_______1. Attend meeting ___/____4. Give donations
people?
POSITION
1. .Raffy Marsan _Kagawad
2.Jun Balcita Kapitan
3.______________________________________ _______________________
4.______________________________________ _______________________
5.______________________________________ _______________________
Interviewer: Jameca Manzano


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COLLEGE OF NURSING

CARLATAN, SAN FERNANDO CITY, LA UNION

FAMILY ASSESSMENT GUIDE

Family Name: Corpuz / Pagdildilan (Barangay)

FAMILY MEMBER’S CHART

FAMILY MEMBERS AGE SEX CIVIL POSITION IN RELATIONSH OCCUPATION

Type of Family Structure

General Family Relationship/Dynamics

Family Dietary Habits

below Ph 5,000 ✔ above PhP 20,000- 30,000 __________

FAMILY HEALTH STATUS/HEALTH HISTORY

FELT FAMILY NEEDS (Identify and rank according to priority)

V. HEALTH and HEALTH PRACTICES

VI. KIND OF NEIGHBOORHOOD

V. AWARENESS OF COMMUNITY ORGANIZATION

Interviewer: Julie Anne Mae P. Acosta

Clinical Instructor: Michelle Sandoval & Ma. Lourdes Inaldo

FAMILY ASSESSMENT GUIDE

Family Name: Corpuz / Pagdildilan (Barangay)

FAMILY MEMBER’S CHART

FAMILY MEMBERS AGE SEX CIVIL POSITION IN RELATIONSHIP OCCUPATION

Type of Family Structure

General Family Relationship/Dynamics

Family Dietary Habits

Monthly Family Income Source

below Ph 5,000 ✔ above PhP 20,000- 30,000 __________

FAMILY HEALTH STATUS/HEALTH HISTORY

FELT FAMILY NEEDS (Identify and rank according to priority)

V. AWARENESS OF COMMUNITY ORGANIZATION

Interviewer: Vladimir C. Otanes

FAMILY ASSESSMENT GUIDE

Family Name: Guray / Pagdildilan (Barangay)

FAMILY MEMBER’S CHART

FAMILY MEMBERS AGE SEX CIVIL POSITION IN RELATIONSHIP OCCUPATION

Type of Family Structure

General Family Relationship/Dynamics

Family Dietary Habits

below Ph 5,000 ✔ above PhP 20,000- 30,000 __________

FAMILY HEALTH STATUS/HEALTH HISTORY

FELT FAMILY NEEDS (Identify and rank according to priority)

V. AWARENESS OF COMMUNITY ORGANIZATION

Interviewer: Julie Anne Mae P. Acosta

FAMILY ASSESSMENT GUIDE

Family Name: Viluan / Pagdildilan (Barangay)

FAMILY MEMBER’S CHART

FAMILY MEMBERS AGE SEX CIVIL POSITION IN RELATIONSHIP OCCUPATION

Type of Family Structure

General Family Relationship/Dynamics

Family Dietary Habits

below Ph 5,000 ✔ above PhP 20,000- 30,000 __________

FAMILY HEALTH STATUS/HEALTH HISTORY

FELT FAMILY NEEDS (Identify and rank according to priority)

XII. KIND OF NEIGHBOORHOOD

V. AWARENESS OF COMMUNITY ORGANIZATION

Interviewer: Julie Anne Mae P. Acosta

Clinical Instructor: Michelle Sandoval & Ma. Lourdes Inaldo

FAMILY ASSESSMENT GUIDE

Family Name: Corpuz / Pagdildilan (Barangay)

Types of Drainage System ___/_ Open __________ Closed

below Ph 5,000_ above PhP 20,000- 30,000 ______

I. Source of water ✔ owned _____bought shared

_2. Exercises YES✔ NO__

_3. Relaxation Activities YES✔ NO__

_4. Stress management YES✔ NO__

below Ph 5,000_ above PhP 20,000- 30,000 ______

I. Source of water _owned ✔ bought shared

______influenza_stomach pains ✔ headache

_2. Exercises YES ✔ NO__