FAMILY HEALTH ASSESSMENT Head of the Family:_________________________________________________________________ Date:________________________ Address (include important landmarks):_________________________________________________ _________________________________________________________________________________ I.

Assessment of the Family A. Members of the Household Relation to Head Birth Date S A e g x Month Year e Marital Status Highest Education Occupation Type of Work Place Immunization Status Physical Health

NAME

B. Type of Family Form: C. Cultural and Religious Orientation:

D. Social Class Status: 1. Breadwinner: 2. Average Monthly Family Income: E. Recreational or Leisure time activities: ____________________________________________ __________________________________________________________________________ II. PHYSICAL ENVIRONMENT A. Home 1. Ownership: House: Lot:

( ) Owned ( ) Owned

( ) Rental ( ) Rental

( ) Rent-Free ( ) Rent-Free ( ) Mixed

( ) Others ( ) Others ( ) Strong

2. Construction materials used: ( ) Light 3. Number of rooms used for sleeping: 4. Specific room for ( ) kitchen and ( ) dining.

5. Furniture: ( ) None ( ) Limited ( ) Adequate 6. Home appliances present: ____________________________________________________ 7. Lightning facilities: ( ) Electricity ( ) Kerosene ( ) Others, specify: ___________________________________ 8. Safety hazards: ( ) loose rickety stairs ( ) loose doors, walls, post windows: ( ) none, ( ) only 1, ( ) more than 1 sharps and matches within reach of children? Yes/No Medicines and poisonous substance kept side by side? Yes/No ( ) Electric stove ( ) Firewood/charcoal ( ) Open drainage ( ) Gas stove ( ) Closed drainage

B. Kitchen 1. Cooking facility: 2. Sanitary condition Drainage facility:

C. Water Supply Please indicate water source by placing a check mark () in the appropriate column. SOURCE 1. Natural spring 2. Electric water pump 3. Open well (tabay) 4. Piped system 5. Artesian well (bomba) 1. Distance from the house: ___________ (m) PUBLIC PRIVATE

2. Collection containers: CONTAINER a. bottles b. cans c. pails d. others (specify) 3. Storage a. b. c. d. e. f. CONTAINER Jar (banga) w/ faucet Jar (banga0 w/o faucet Can Pitcher Pail Others

WITH COVER

WITHOUT COVER

WITH COVER

WITHOUT COVER

D. Waste Disposal 1. Toilet a. Type: TYPE Open pit privy Bored-hole latrine Antipolo system Pail system Closed pit privy Overhung latrine Flush type Water sealed Other (speficy) OWNED SHARED

b. Distance from the house: _________________ (m) c. Sanitary conditions (describe) ________________________________________________ __________________________________________________________________________ 2. Refuse and Garbage a. Container: CONTAINER a. Plastic b. Sack c. Can d. Steel drum e. Others ( ) No container used

COVERED

WITHOUT COVER

b. Method of disposal ( ) hog feeding ( ) open dumping ( ) burning ( ) buried in pit ( ) composting ( ) motorized collection system ( ) others, specify ______________________________________________________________________

E. Domestic Animals KIND

NUMBER

WHERE KEPT

F. The Community in General 1. Type of community: RESIDENTIAL AREA Rural Urban Suburban 2. Accessible to: (encircle) a. transportation b. church c. school d. market e. shopping center f. health agency 3. 4. 5. 6. 7. 8. YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO INDUSTRIAL AREA

Congested neighbourhood: YES/NO Recreational facilities present: ____________________________________________ Health care facilities present: _____________________________________________ Distance of house to the nearest health care facility: _______________ (m) Family perception of this community _______________________________________ Family associations and transactions with the community: a. What community services are usually utilized by the family? ____________________________________________________________________ b. Who in the family uses these community services? ____________________________________________________________________ c. Frequency of community service utilization? _____________________________ d. Familys perception of the agency from whom its receives assistance. _________ ____________________________________________________________________

III.

PSYCHO-SOCIAL ENVIRONMENT A. Family Strenghts and Weaknesses: Strengths ____________________________________________________________ ____________________________________________________________________ Weaknesses __________________________________________________________ ____________________________________________________________________

B, Family Communication 1. Usual patterns: 2. Purposes:

( ) wheel ( ) chain

( ) isolate ( ) switchboard

3. Rules observed during interactions: C. Family Stage of Development 1. Present stage: 2. Developmental task demonstrated by the family at the present stage: D. Role Structure FAMILY MEMBER FORMAL ROLE INFORMAL ROLE

E. Power Structure Decisions to be made 1. Major family purchases 2. Daily household expenses 3. Child-rearing practices 4. Social activities 5. Household activities 6. Discipline 7. Health-illness matters

Decision maker

Decision-making process

Over-all family power typology ( ) chaotic (leaderless) family ( ) egalitarian (shared power) family ( ) syncretic (mutual commitment) ( ) automistic (automatic or independent commitment) ( ) autocratic ( ) husband-dominate family ( ) wife-dominated family

F. Family Values 1. Identified and practiced moral values .

2. How do these family values affect the health status of the family?

G. Family Coping Functions 1. Short-term stressors 2. Long-term stressors 3. Family strengths which counterbalance stressors 4. Functional coping strategies utilized by the family (past & present) IV. I. HEALTH RELATED BEHAVIORS Family attitude towards: 1. health: __________________________________________________________ ________________________________________________________________ 2. illness: __________________________________________________________ ________________________________________________________________ Health care facilities: 1. usual source of health care __________________________________________ 2. frequency of visit to the health care facility _____________________________ 3. member of family who usually utilizes health care services: ________________ 4. means of financing health care _______________________________________ 5. barriers to obtaining health care ______________________________________ Dental Health Practices:

II.

III.

IV.

Family Medical History:

V.

Family Drug habits:

VI.

Nutrition 1. dietary practices and food allergies 2. food history record SAMPLE MENU FOR ONE DAY MEAL FOOD SERVED QUANTITY INDIVIDUAL DIFFERENCES

3.

market practices

VII.

Sleep and Rest practices TIME FOR SLEEPING TIME FOR WAKING SLEEPING AIDS USED, IF ANY

FAMILY MEMBER

V.

FURTHER ASSESSMENT DATA NEEDED:

Interviewer: _____________________________

Criteria 1. Nature of the problem

Computation

Actual Score

Justification

2. Modifiability of the problem 3. Preventive potential

4. Salience of the problem Total Score

Criteria 1. Nature of the problem

Computation

Actual Score

Justification

2. Modifiability of the problem 3. Preventive potential

4. Salience of the problem Total Score

Criteria 1. Nature of the problem

Computation

Actual Score

Justification

2. Modifiability of the problem 3. Preventive potential

4. Salience of the problem Total Score

Criteria 1. Nature of the problem

Computation

Actual Score

Justification

2. Modifiability of the problem 3. Preventive potential

4. Salience of the problem Total Score

FAMILY NURSING CARE PLAN HEALTH PROBLEM FAMILY NURSING PROBLEMS GOAL OF CARE OBJECTIVES OF CARE INTERVENTION PLAN Nursing Method of Nurseinterventions Family Contact Resources required

FAMILY NURSING CARE PLAN HEALTH PROBLEM FAMILY NURSING PROBLEMS GOAL OF CARE OBJECTIVES OF CARE INTERVENTION PLAN Nursing Method of Nurseinterventions Family Contact Resources required

FAMILY NURSING CARE PLAN HEALTH PROBLEM FAMILY NURSING PROBLEMS GOAL OF CARE OBJECTIVES OF CARE INTERVENTION PLAN Nursing Method of Nurseinterventions Family Contact Resources required