FAMILY HEALTH ASSESSMENT FORM

Respondent:_________________________________; Age:__________

Stage:_______________________________________; Sex:__________

Relation to Head:________________ (If not the Head of the Family)

I. Family Data
A. Head of the family______________________________ Age_________

B. Name of Spouse_______________________________ Age_________

C. Address_______________________________________Tel No.___________

Household Elementary Elementary High School High School College College

Member (Undergrad) (Graduate) (Undergrad) (Graduate) (Undergrad) (Graduate

HUSBAND
WIFE
D. Educational Attainment:

E. Length of Residency_____________________________

F. Ethnic Origin___________________________________

G. Family

Nuclear ( ) Extended ( )

H. Religion

Roman Catholic ( ) INC ( )

Jehovah’s Witnesses ( ) Adventist ( )

Other:__________________

I. No. of Children_______________
 Name Relation to Head Age Sex Status Education Occupati

J. Members of the Household

II. Socio-economic Data

A. Source of Income

B. Occupation:

Husband:

Employed ( ) Unemployed ( )

Wife:

Employed ( ) Unemployed ( )
Joint Monthly Income
Below ₱2,000 ( ) ₱3,000 - ₱5,000 ( )
₱5,000 - ₱8,000 ( ) more than ₱8,000 ( )

B. Basic Expenditures
1. Food Daily
below ₱50 ( ) ₱50 - ₱75 ( )
more than ₱75 ( )

2. Clothing: number of times of buying in a year

once ( ) twice ( )
thrice ( ) more than four times ( )

3. Housing
water ( ) electricity ( )
cellphone load ( )

4. Schooling
public ( ) private ( )

5. Others________________________________________

C. Nutrition
1. Food preference
fish ( ) fruit/vegetables ( )
meat ( ) mixed ( )
2. Common fare
rice and egg ( ) rice and sardines ( )
rice and noodles ( ) Others________________

III. Housing and Environmental Condition

A. Home
1. Type of Housing
concrete ( ) wood ( )
mixed ( ) makeshift ( )
2. Ownership
 owned ( ) rented ( )
rent-free ( ) others:_____________

3. Number of rooms for sleeping:__________________

4. Ventilation:
poor ( ) good ( )
5. Lighting Facilities:
electricity ( ) kerosene ( )
others:_______________
6. General Surroundings:
clean ( ) dirty ( )

Sanitary Observations:__________________

B. Source of Water Supply

artesian well ( ) deep well ( )
NAWASA ( ) others:_______________

C. Storage of Drinking Water

refrigerated ( ) covered ( )
uncovered ( )

D. Appliances
refrigerator ( ) stove ( )
electric fan ( ) TV ( )

E. Kitchen
electric stove ( ) gas stove ( )
firewood/charcoal ( )

F. Drainage
 open ( ) blind ( )
none ( )
Sanitary observations: ______________
G. Containers Used
plastic ( ) jars ( )
bottles ( ) others:______________

H. Toilet Facilities
Sanitary:
flush ( ) pit privy ( )
shared ( ) owned ( )
others: _______________
Unsanitary:
“balot” system ( ) others:_____________
I. Waste Disposal
collection ( ) burning ( )
burying ( ) open dumping ( )
garbage cans ( ) others:______________
J. Food Storage
covered ( ) uncovered ( )
refrigerated ( )
K. Presence of Animals
dogs ( ) cats ( )
pigs ( ) others:________________
L. Backyard Gardening:
vegetables ( ) herbal ( )
fruit-bearing ( ) others:______________
M. Consultation
health center ( ) hilot ( )
hospital ( )
N. Transportation
 tricycle ( ) pedicab ( )
walking ( ) jeep ( )
bicycle ( ) others _______________

O. Community Observation
A. Sanitary Condition:____________________________________
B. House Overcrowding/ Congestion Yes ( ) No ( )
C. Presence of breeding sites of vectors: Yes ( ) No ( )
If yes, specify:___________________
D. Health facilities:______________________
E. Recreational facility:_____________________
F. Distance of house to the nearest health care facility:_____________________