Professional Documents
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Family Health Assessment: 1. Identification Information
Family Health Assessment: 1. Identification Information
1. IDENTIFICATION INFORMATION
Head of Family: Arman Abordo
Ethnicity: Bicolano
2. HOUSING CONDITION
I. Type of House: Completed Partially Completed Independent
3. FAMILY COMPOSITION
RELATIONSHIP
HEALTH IMMUNIZATION
SN NAME WITH HEAD OF AGE SEX OCCUPATION/EDUCATION STATUS STATUS
FAMILY
10
11
12
Telephone
Television
Radio
Newspaper/Magazine
Cellphone
5. LANGUAGE KNOWN
Tagalog Ilocano Bicol
English Bisaya Any Other:
_________________
6. A. NUTRITIONAL PATTERN
✓ VEGETARIAN ✓ NON-VEGETARIAN
Staple Food: Rice Wheat Ragi Mixed
Vegetables: Grown Purchased Quantity used per day:
Milk: Quantity used per day: Half to whole liters
Non-vegetarian dish: Specify: How often:
HEIGH
AGE WEIGHT
T
- When was the last time you visited the doctor/health center for a routine check-up?
Within the last 12 months Within the last 2 years
Between 2-5 years Over 5 years ago
I have never had a routine check-up/visit
- Are you able to visit a doctor/health care worker when needed?
Always Sometimes Seldom Never
- Which of the following have stopped you from getting the health care you need? (Check all that
apply)
Too expensive
Lack of transportation
Health worker is not attending
Others, please specify: ________________________________
- Select any of the following preventive procedures you have had in the last year.
Vaccination, please specify
BP Check-up Prostate screen
Cholesterol screen Dental cleaning
Blood Sugar check Mammogram
ECG Colon/Rectal Examination
Vision screening Pap smear
Hearing screening Others, please specify _________________
IF NOT PREGNANT:
10. Are you currently using contraceptive or birth spacing method? __ YES ✓ NO
If YES, what method are you using? __________________________________
If NO, have you ever used any contraception or birth spacing method in the past?
✓ YES __ NO
If YES, what method are you using in the past? Contraceptive Pill
If NO, why have you not used a contraceptive or birth spacing method? _____________
________________________________________________________________________
________________________________________________________________________
9. HEALTH
a. Where do you go if you or any of your family member is sick? Clinic/Hospital
b. Who do you consult when you or any of your family member is sick? Physician
c. When was the last time you or any of your family member had consultation/visit to the
doctor? For what reason: March 16, 2021/ TONSILITIS & UTI
d. When was the last time you or any of your family member visit a dentist? 2019
e. Is there any medication that is currently being taken by you or any of your family member?
__ YES ✓ NO
If YES, please name them:
f. Is any member of the family currently with sickness or condition? __ YES ✓ NO
What is the sickness/medical condition?
h. Is there death in the family for the past year? __ YES ✓ NO
If YES, for what reason? ___________________________________________________
i. Have you attended any health-related meetings or seminar? __ YES ✓ NO
If YES, what is the topic? ___________________________________________________
If NO, what is the reason why you don’t attend a health-related seminar, meetings, and
the like? I have no time to attend such seminars.
j. Which of the following do you think are the FIVE most important factor a healthy community?
Please check 5 only.
_✓ Child care
_____ Prenatal/Postnatal care
_____ Low death rate
_____ Low illness rate
_✓ Healthy behavior and lifestyle
__ Healthy food sources
_✓ Clean and safe environment
_✓ Low level of child abuse
_✓ Emergency and disaster preparedness
Others, please specify: ___________________________________________________________
Prepared by:
Checked by: