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FAMILY CARE STUDY Introduction Spot Map Family
FAMILY CARE STUDY Introduction Spot Map Family
FAMILY CARE STUDY Introduction Spot Map Family
Introduction
Spot Map
Family Profile
Actual Implementation
Evaluation
FAMILY PROFILE
Name Gender Birth date Age Highest Education Completed Occupation Income
Immunization
Family Planning
Methods
Natural Method Permanent Method Temporary Method Wala
Heredo-Familial Disease
( ) Hypertension
( ) Cancer
( ) Asthma
( ) Diabetes
( ) Arthritis
( ) Mental Retardation
PAST FAMILY HISTORY
Allergies
HOME
b. General sanitary condition: ____________________________
a. Ownership: ( ) Owned ( ) Rented ( ) Rent-free
b. Construction materials used: ( ) Light ( ) Mixed ( ) Strong
c. Number of rooms used for sleeping: _____________________
d. Lighting Facilities: ( ) Electricity ( ) Kerosene ( )
Others______________
e. General sanitary condition: ________________________________________
WATER SUPPLY
a. Drinking water
Source: ( ) Private ( ) Public
Distance from the house: ______________________________________
Storage: ( ) None, direct from the faucet
( ) Container with cover
( ) Container without cover
( ) Others ______________________________________
KITCHEN
a. Cooking facility: ( ) Electric stove ( ) Gas Stove ( )
Firewood/Charcoal
DRAINAGE SYSTEM
a. Drainage facility: ( ) None ( ) Open drainage ( ) Blind/close
drainage
WASTE DISPOSAL
a. Garbage disposal
1. Container: ( ) Covered ( ) Open ( ) None
2. Method of disposal: ( ) Opening dumping ( ) Open burning
( ) Compost pit
b. Toilet
1. Type
( ) Pit privy ( ) Pail system
( ) Flush type ( ) Antipolo System
( ) Water-sealed ( ) none
c. Distance: ______________________________________________________
d. General sanitary condition: ________________________________________
DOMESTIC ANIMALS: