COMMUNITY HEALTH NURSING SURVEY FORM

Name:Erwin Jhon RopaAge:1 y/oDate of Birth:March 10,2013Address:67 Orange rd. Potrero, MalabonMother's Name:Joyce DizonFather's Name:Ednil RopaContact no.:0912-383-8327

Family Structure and Characteristics

-Type of Family Structure*Nuclear Family-No. of the household*3 members

Socio-economic and Cultural Characteristics

-Occupation*Father:none*Mother:none-Monthly Income*none

Home and Environment

-Type of Home*Mixed-Presence of Vector of Diseases*Cockroaches, Flies, Mosquito, Rats-Food Storage*They only buy foods on the store for their own.-Cooking Facilities*Gas Stobe-WaterSupplies*They only get water supplies to theircommunity.

-Toilet Facilities*Water sealed-Garbage Disposal*DPS-Social Facilities Available*Church & Clinic

Health Status of Each Member

-Past History of the Family*There is no history ofdiseases from their family.-Hospitalizationnone-Anthometric Measurement*BMI= W(11kg)/H(52cm)=40.68 BMI-Diet History*Eating vegetables, fruits and meats

-Diagnostic Procedure Done*none

Values and Habits

-Exercises*none-Relaxation Technique*Sleeping-Immunization Procedure*Complete Vaccine

Submitted by:Mary Joy C. LunaBSN2-1