Professional Documents
Culture Documents
Family Health Assessment Form
Family Health Assessment Form
Family Health Assessment Form
Respondent:_________________________________; Age:__________
Stage:_______________________________________; Sex:__________
I. Family Data
A. Head of the family______________________________ Age_________
C. Address_______________________________________Tel No.___________
HUSBAND
WIFE
D. Educational Attainment:
E. Length of Residency_____________________________
F. Ethnic Origin___________________________________
G. Family
Nuclear ( ) Extended ( )
H. Religion
Other:__________________
I. No. of Children_______________
Name Relation to Head Age Sex Status Education Occupati
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 ( )
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________________
Sanitary Observations:__________________
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:_____________________