University of Southern Mindanao

COLLEGE OF HEALTH SCIENCES

Kabacan, Cotabato

FAMILY HEALTH ASSESSMENT TOOL

Date of Interview: _________________ Name of Nursing Student: ____________________

Barangay: ____________________ Purok: ____________________________________

Name of Respondent: ______________________

HOUSEHOLD PROFILE
A. National Household Targeting System (NHTS) (Tick one)
 NHTS (Indigent Philhealth)
 NON-NHTS
 4Ps

B. Solid Waste Management (Tick all that apply)

 Throwing
 Burning
 Compost Pit
 ESWM (Ecological Solid Waste Management)

C. Toilet Facility (Tick all that apply)

 Sanitary (Owned)
 Sanitary (Shared)
 Unsanitary

D. Drinking Water Source

 Level I (Point Source)
 Level II (Communal Faucet System or Standposts)
 Level III (Waterworks System or Individual House Connections)
 Doubtful

E. Pet/s (Tick all that apply)

 Dog
 Cat
 Others(specify): __________________

F. Electricity
 With electricity
 Without electricity
 FAMILY STRUCTURE AND CHARACTERISTICS
A. Household Members
Name Date of Age Sex Civil Educational Occupation Relationship to
Birth Status Attainment Head of Household

B. Family Members living outside of the household

Name Date of Age Sex Location Occupation Means of Frequency of Relationship

Birth Communication Communication to Head of
with Household with Household Household

C. Type of Family in Terms of Structure

 Nuclear
 Extended
 Other (please specify) ________________

D. Genogram, Family Tree and Ecomap

 FAMILY HEALTH PROFILE

A. General Health Profile

Name PhilHealth Blood Height Weight BMI PCV Flu Alcohol Smoker Senior Indigenous PWD
Number Pressure (in cm) (in kg) given Vaccine Drinker Citizen Peoples (specify)

B. Family Planning for Women of Reproductive Age (10 – 49 years old)

Name Family Planning Status Family Planning Method Reasons for Using this Method Remarks

NA CU DO NU Unmet
 C. Pregnant Women and Postpartum
Name LMP EDC OB SCORE PNC Visits TT Vit AOG Type of Attendant Place of Postpartum Ferrous
A Delivery Delivery Visits Sulfate
G P A L 1st 2nd 3rd

D. Newborn Profile
Name of Newborn BCG Vaccine Given Hepa B Vaccine Newborn Screening Initiated Remarks
Given Breastfeeding 1 hr
after delivery

E. Expanded Program on Immunization (0 – 23 months old)

Name of BCG OPV IPV Pentavalent MCV Immunization Status Vitamin A Complementary Nutritional
Infant Feeding Status
1 2 3 1 2 3 FIC CIC INC None Jan July

F. Garantisadong Pambata (1 – 19 years old)

Name of Child Deworming Vitamin A Nutritional Status School-Based Immunization Remarks
January July January July MR TT HPV
 G. Noncommunicable Diseases
Name Hypertensive Diabetes Goiter Mass Cancer Others With Without Name of
Mellitus (Specify) (Specify) Medication Medication Medications

H. Communicable/Infectious Diseases
Name Two weeks cough or Malaria Filariasis Dengue Schistosomiasis Leprosy Sexually With Name of
unexplained cough of Transmitted Medication Medication
any duration in close Infections
contact
Yes/No Sputum
Collected
Yes No
FAMILY MOBILITY AND FAMILY DYNAMICS
A. Length of stay at current address (years and months):______________________
B. Address of previous residence: __________________________
C. How many times have you moved residence in the past 5 years? ____________
Reason/s for moving: _______________________________________________

D. Emotional bonding of the family members

________________________________________________________________
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E. Distribution of authority and power

________________________________________________________________
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F. Degree of individual autonomy

________________________________________________________________
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G. How members of the family communicate

________________________________________________________________
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H. How decisions are made

________________________________________________________________
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I. How problems are solved

________________________________________________________________
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J. How conflict is handled

________________________________________________________________
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K. Division of labor
________________________________________________________________
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SOCIOECONOMIC AND CULTURAL CHARACTERISTICS
A. Languages/Dialects spoken
________________________________________________________________
________________________________________________________________

B. Degree of social network with friends, neighbors, and other relatives

________________________________________________________________
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C. Network with religious and social organizations

________________________________________________________________
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D. Leisure Time Interests

________________________________________________________________
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E. Estimated monthly household income: ________________________________

F. Management of financial resources

________________________________________________________________
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G. Cultural influences. Describe family’s values, attitudes and beliefs about:

Spirituality
________________________________________________________________
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Dietary Habits
________________________________________________________________
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Health
________________________________________________________________
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Folk Diseases
________________________________________________________________
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 ________________________________________________________________

Traditional Healers
________________________________________________________________
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FAMILY HEALTH ENVIRONMENT

Family Residence. Describe the residence in terms of:

Adequacy of Size
________________________________________________________________
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Structural Safety
________________________________________________________________
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Water and Sanitation

________________________________________________________________
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Food preparation and storage

________________________________________________________________
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Sewage
________________________________________________________________
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Garbage disposal
________________________________________________________________
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Excreta Disposal
________________________________________________________________
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Pest and vermin control

________________________________________________________________
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Family Neighborhood
A. Location
 Urban
 Semi-Urban
 Rural
 Slum

B. Type of Neighborhood
 Residential
 Commercial
 Semi-commercial

C. Safety (Describe the general safety of the neighborhood in terms of lighting,

presence of security mechanisms, traffic patterns, etc)
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

D. Population density (crowding)

_____________________________________________________________
_____________________________________________________________
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E. Sources of Pollution (Air, Water, Soil, Noise, etc.. – Describe)

_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

Family Health and Health Behavior

A. Activities of Daily Living (Describe how family spends a typical day)
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

B. Health History (pregnancy, illness, death within the past 5 years)

_____________________________________________________________
_____________________________________________________________
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C. Self-care (Describe the health promotion and disease prevention activities done by
the family)
_____________________________________________________________
 _____________________________________________________________
_____________________________________________________________

D. Risk Behaviors
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

E. Health Status (problems and priorities)

_____________________________________________________________
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F. Home Remedies
_____________________________________________________________
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G. Health Care Resources (including health workers and health agencies)

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