FAMILY CASE STUDY FORMAT
TITLE PAGE
ACKNOWLEDGMENT
TABLE OF CONTENTS
CHAPTERS
I. Introduction
II. Purpose of the Study
a. Goal or General Objectives
b. Specific Objectives
III. Family Data Base
A. Family Structure, Characteristics and Dynamics
1. Name and Address of Household Head
2. Household Members: Name, Age, Sex, Civil Status, Position in the Family
3. Type of Family Structure – patriarchal, matriarchal, nuclear or extended
4. Dominant family members in terms of decision making especially in matters of health care
5. General family relationship / dynamics
B. Socioeconomic and Cultural Characteristics
1. Educational attainment of each members
2. Income and Expenses
3. Ethnic background and Religious Affiliation
4. Relationship of the family to the larger community
C. Home and Environment
1. Housing
2. Kind of neighborhood
3. Social and Health facilities available
4. Communication and Transportation facilities available
D. Health Status of each Family Members
1. Medical and Nursing History
2. Nutritional Assessment
3. Risk factor assessment indicating presence of major contributing modifiable risk factors for
specific lifestyle illness
4. Physical Assessment indicating presence of illness state
E. Values, Habits, Practices on Health Promotion, Maintenance and Disease Prevention
1. Immunization Status of the family members
2. Deworming of Family members
3. Healthy lifestyle practices
4. Use of promotive – preventive Health Services
IV. Family Coping Index
Criteria Ideal Actual Rating Justification
V. Typology of Nursing Problem
Cues/Data Health Problems Family Nursing Problems
VI. Problem Prioritization and Problem Ranking
Criteria Computation Actual Score Justification
VII. Family Nursing Care Plan
Health Family Goal of Specific Intervention Plan Evaluation
Problem Nursing Care Objectives Nursing Method of Resources
Problem of Care Intervention Nurse Required
family
Contact
VIII. Summary / Conclusion
BIBLIOGRAPHY
APPENDICES
Pictorials/Documentation
Family Health Profile
Health Data Card
Actual Family Visit Record
CURRICULUM VITAE
