University of San Agustin

College of Pharmacy and Medical Technology

Family Assessment Sheet

Name of Interviewee: _________________________________ Interviewer:_________________________________________ Address: ________________________

Name

Age

Sex

Civil Status

Religion

Length of residency

Educational Attainment

Literate (Y/N)

Occupational Status (employed, underemployed, unemployed, self-employed)

Type of occupation

Monthly Income

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Type of Family Nuclear Type of Housing Lot: Rented owned House: Rented owned Type of House: Concrete Wood Makeshift Combination/Mixed Environment Type of Community: Rural Lighting: Sufficient Insufficient Urban Owned Not Owned Not Extended

Water Supply: Deep Well (point source) Communal (faucet system, standpost) Water works system/distribution Others specify:____________ Excreta Disposal: Water Sealed Latrine Tank Balot System/Wrap & Throw Latrine Others specify:____________ Garbage/ solid waste/ refuse disposal: Open dumping Collected Burying Burning Septic Pit

Health Profile of the Family Food storage: Refrigerated Non-refrigerated Covered Uncovered Is there an infant? Yes
questions if no)

No (Skip the next 2

Infant feeding: Exclusive Breastfeeding Mixed Immunization status: Has the infant been immunized? Bottle Feeding Su-am

Practice Waste Segregation Yes No Others specify:______________ Pets/Domesticated Animals: If any, specify: _______________ Food source animal: If any, specify:________________

Yes BCG AMV No DPT- number of shots: ____ OPV- number of shots: ____

Source of Lighting: ______________ Ventilation: Sufficient Insufficient

Health Seeking Behaviors Recently experienced illness: Specify: _____________ Where did you seek for health care? Barangay Health Center Private Clinic Hospital Public Private Quack doctor (Albularyo) None

Others specify: ______________ Family Planning Are you practicing family planning? Yes Natural Calendar BBT Cervical mucus Withdrawal Artificial Hormonal Barrier Surgical No Pregnant Mother Are you pregnant? Yes Last pre-natal check up:___________ No

Nearest Health Facility _________________________ Nearest recreational park _________________________ Nearest Public School _________________________ Nearest Public Market _________________________ Nearest Drug Store _________________________ Communication Where do you get your health information from? Health Center Personnel Newspapers/ Fliers/ Posters Radio Television Phone Internet