Family Name Address

I. Family Data
Length of residency: ____________________
Place of origin: ____________________
____________________
Family Size: ____________________
Religion: Husband— ____________________
Wife— ____________________

Family Member’s Chart

FAMILY AGE SEX CIVIL POSITION RELATIONSHIP EDUCATIONAL OCCUPATION

MEMBERS STATU IN THE TO FAMILY ATTAINMENT
S FAMILY HEAD

1
2
3
4
5

II. Family Characteristics

Type of Family Structure
A. Extended _____ D. Nuclear _____
B. Matriarchal _____ E. Patriarchal _____
C. Dominant Family Member __________
Family Dietary Habits
What did you eat yesterday? (24 hours dietary recall)
Breakfast : _________________________________________________________
Lunch : _________________________________________________________
Dinner : _________________________________________________________
 Monthly Family Income Source
Husband : _________________________________________________________
Wife : _________________________________________________________
Others : _________________________________________________________
Monthly Family Income Source
Total (check bracket)
below ₱5,000 _____ above ₱20,000-30,000 _____
above ₱5,000-10,000 _____ above ₱30,000-40,000 _____
above ₱10,000-15,000 _____ above ₱40,000-50,000 _____
above ₱15,000-20,000 _____ more than ₱50,000 _____
Family Health Status/Health History
Father : _________________________________________________________
Mother : _________________________________________________________
Children : _________________________________________________________
Felt Family Needs (identify and rank according to priority)
1. 5.
2. 6.
3. 7.
4. 8.
IV. Home and environment
A. Is your lot owned?
_____ Yes _____ No
B. Is your house owned?
_____ Yes _____ No
C. Type of housing materials
_____ wood _____ mixed
_____ concrete _____ makeshift
others, specify__
D. Is the living space adequate? _____ (Yes) _____ (No)
E. What are the appliances owned by the family?

F. Type of garbage disposal

 _____ collected _____ burning
_____ waste segregation _____ burying
_____ feeding to animals _____ throw in the river/sewer
_____ open dumping _____ others, specify__
G. Type of waste disposal
_____ flush _____ water-sealed
_____ wrap and throw _____ pit privy
_____ others, specify_________
H. Type of drainage system _____ Open _____ Closed
I. Type of water supply
_____ owned _____ shared
_____ bought _____ others, specify_________
J. Drinking water storage
_____ refrigerated _____ covered
_____ uncovered
K. Containers used
_____ plastic pitchers _____ others, specify______
_____ bottles

L. Food storage/cooking facilities

_____ covered _____ uncovered _____ stove
_____ refrigerator _____ cabinet _____ pots/pans, etc.
M. Common household pets found at home

N. Are there sites of insects, rodents, etc. present? _____ (Yes) _____ (None)
O. Pets/animals kept in the yard/home

P. Are there accident hazards present? _____ (Yes) _____ (None)

V. Health and health practices

A. Common illnesses encountered for the last 6 months and the treatment applied.
 B. Whom do you consult for health related problems?
_____ manghihilot _____ albularyo
______ midwife _____ nurse
_____ doctor _____ Health Center
______ Barangay Health Worker _____ others, specify _______

C. For problems other than health, whom of you consult?

_____ family members _____ relatives
______ friends _____ Barangay officials
_____ priest _____ others, specify ________
D. Immunization status of family members

E. Have you had adequate

1. rest and sleep _____ (Yes) _____ (No)
2. rest and sleep _____ (Yes) _____ (No)
3. rest and sleep _____ (Yes) _____ (No)
4. rest and sleep _____ (Yes) _____ (No)
VI. Environment

1. Kind of Neighborhood

2. Social and health facilities available

1. Communication and Transportation facilities

VII. Awareness of community Organization

A. Are you aware pf existing organisations in the community?
________ Yes ________ No
B. Name all the organization/s you know.

C. Are you a member of any of these organizations?

________ Yes ________ No
D. Are you aware of its activities and projects?
________ Yes ________ No
E. How are you involved in its activities
________ attend meetings ________ give donations
________ planning ________ evaluation
________ implemenation ________ others, specify _________