Family Health Assessment

Respondent: Age:
Relation to head: Sex:
Address:

I. Family Data

Head of The family: Age:

Name of spouse: Age:
Address:
Educational Attainment
i. Husband:
ii. Wife:
Ethnic Origin:
Family:
Nuclear ( ) Extended ( )
Religion:
No of children:

Members of the household

Name Age Sex Relation to the Marital Educational Occupation Remarks
head Status Attainment

II. Socio-economic Data

A. Source of Income

i. Husband
Occupation:
Employed ( ) Unemployed ( )

Self-Employed ( )
 ii. Wife
Occupation:
Employed ( ) Unemployed ( )

Self-Employed ( )

iii. Joint monthly income

Below 2000php ( ) 3000-5000php ( )

5001-8000php ( ) more than 8000php ( )

B. Basic Expenditures

i.Food Daily:

Below 50php ( ) 50-75 php ( )

More than 75php ( )

ii. Clothing: Number of times buying in a year

Once ( ) Twice ( )

Thrice ( ) More than 4 times ( )

iii. Housing:

Water ( ) Electricity ( )

Cable ( ) Telephone ( )

iv. Schooling:

Public ( ) Private ( )

Home Schooled ( )
 C. Nutrition

i. Food Preference:

Fish ( ) Fruit/Vegetables ( )

Meat ( ) Mixed ( )

ii. Common Fare:

Rice and egg ( ) Rice and Sardines ( )

Rice and noodles ( ) others:

III. Housing and Environment Condition

A. Home

i. Ownership:

Owned ( ) Rent ( )

Rent-free ( ) Others

ii. Type of Housing:

Concrete ( ) Wood ( )

Mixed ( ) Makeshift ( )

iii. Number of rooms for sleeping:

iv. Ventilation:

Good ( ) Poor ( )

v. Lightning Facility:

Electricity ( ) Kerosene ( )

Others:
 vi. General Surroundings:

Clean ( ) Dirty ( )

B. Source of water supply:

Artesian Well ( ) Deep well ( )

Others:

C. Storage of drinking water:

Refrigerated ( ) Covered ( )

Uncovered ( )

i.Container used:

Plastic ( ) Jars ( )

Bottles ( ) others:

D. Kitchen

Electric stove ( ) Gas ( )

Firewood/ Charcoal ( )

E. Toilet Facilities:

i.
Owned ( ) Shared ( ) Communal ( )

ii.
Sanitary ( ) Flush type ( ) Close privy ( )

Water sealed ( ) Unsanitary ( ) “ballot” system ( )

Antipolo ( ) Cat hole ( ) Others

F. Waste Disposal :

Hog feeding ( ) Composting ( )

Open dumping ( ) Burial in pit ( )

Collected ( ) Burned ( )

Garbage cans ( ) others

G. Presence of animals

Dogs ( ) Cats( )

Pigs ( ) others

H. Backyard Observation

a. Sanitary condition

b. House overcrowding/ congestion: Yes ( ) No ( )

c. Presence of breeding sits of vectors: Yes () No ( )

if yes, specify

d. Health facilities:

e. Recreational Facility

f. Distance of house to nearest health care facility