SURVEY FORM.docx - INITIAL DATA BASE I. CHARACTERS: What is...

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INITIAL DATA BASEI.CHARACTERS:What is the type of family structures?_____Nuclear_____Patriarchial_____Extended_____Matriarchial
Who maks decision regarding health care? _________________________What is the present family relationship?_________________________with conflicts between members_________________________without conflicts between family membersActivities of daily livingSleeping pattern:Retiring/getting up hours _____________________________Nap during the day ___________________________________Do members sleep together __________________________Eating patternHow many meals each day? ___________________________Who appears overweight?___________________________Who appears underweight? ___________________________Leisure time activitiesHow does each member spend leisure hours?__________________________________________________________________________________Is it appropriate for the sex and age group?__________________________________________________________________________________What is the effect to the family?__________________________________________________________________________________Any joint activivty for leisure?__________________________________________________________________________________II.FAMILY INFORMATIONHead of the family: ________________________________________Address:___________________________________________________________________________Members of the household:
NAMERELATIONSHIPAGEEDUCATIONAL ATTAINMENT
III.SOCIO-ECONOMIC AND CULTURAL FACTORSIncomeNAMEOCCUPATIONPLACEINCOME
Does the working family member meet the basic necessities?__________Yes__________NoWho maks decisions regarding money matters? _______________________________________________Religiousaffiliation:_____________________________________________________________________________Whatrolesdoesthefamilyplayin

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Term
Fall
Professor
N/A
Tags
health care facility

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