The COLLEGE OF MAASIN

Nisi Dominus Frustra

Maasin City , Southern Leyte
College of Nursing

FAMILY HEALTH ASSESSMENT FORM

Family Surname: ____________________________________________________________________________

Purok _________________ Barangay __________________ City/ Municipality _______________________

Source(s) of information _____________________________________________________________________

Data Gathered by ___________________________________ Date _______________________________

Household Members

Name Age Relationship to head of household

Family Characteristics

Family members living outside the household

Name , Age and Relationship to head of household

___________________________________________________________________________________________________

___________________________________________________________________________________________________

Location of family member(s)

__________________________________________________________________________________________________

Frequency and duration of contract

__________________________________________________________________________________________________

Means of communication

__________________________________________________________________________________________________
Family Mobility

Length of time at current address

__________________________________________________________________________________________

Address of previous residence(s)

__________________________________________________________________________________________

Frequency of geographic moves

__________________________________________________________________________________________

Family Dynamics

Emotional bonding of family members

__________________________________________________________________________________________

Distribution of authority and power

__________________________________________________________________________________________

Degree of individual autonomy

__________________________________________________________________________________________

How members communicate

__________________________________________________________________________________________

How decisions are made

__________________________________________________________________________________________

How problems are solved

__________________________________________________________________________________________

How conflict is handled

__________________________________________________________________________________________

Division of labor

__________________________________________________________________________________________
Socioeconomic and Cultural Characteristics

Family Social Integration

Language(s) or dialect(s) spoken

__________________________________________________________________________________________

Literacy ( ability to read or write in language(s)

__________________________________________________________________________________________

Degree of social network with friends , neighbors and other relatives

__________________________________________________________________________________________

Network with religious organizations

__________________________________________________________________________________________

Network with social organizations

__________________________________________________________________________________________

Educational experiences

Work history

Adequacy of financial resources

Leisure time interests

Cultural influences : values, attitudes and beliefs about :

Spirituality
__________________________________________________________________________________________
Rituals ( holidays and celebrations)
__________________________________________________________________________________________
Dietary habits
__________________________________________________________________________________________
Health
__________________________________________________________________________________________
Folk diseases
__________________________________________________________________________________________
Traditional healers
__________________________________________________________________________________________
Family Environment
Family residence
Adequacy of size
__________________________________________________________________________________________
Structural safety
__________________________________________________________________________________________
Water sanitation
__________________________________________________________________________________________
Food preparation and storage
__________________________________________________________________________________________
Sewage
__________________________________________________________________________________________
Garbage disposal
__________________________________________________________________________________________
Excreta disposal
__________________________________________________________________________________________
Pest and vermin control

Family neighborhood
Location ( e.g. urban, rural , subdivision, slum area)
__________________________________________________________________________________________
Type (e.g. residential, semi-commercial)
__________________________________________________________________________________________
Safety : traffic patterns, lighting, security (police or private)
__________________________________________________________________________________________
Population density ( crowding)
__________________________________________________________________________________________
Sources of pollution :
Air ____ Water _____ Soil _____ Noise _____

Family Health and Health Behavior

Activities of daily living (how family spends a typical day)
__________________________________________________________________________________________
__________________________________________________________________________________________
Health history (pregnancy, illness, death within the past 5 years / health attendance)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Self-care ( health promotion and disease prevention)
__________________________________________________________________________________________
__________________________________________________________________________________________
Risk behaviors
__________________________________________________________________________________________
Health status (problems and priorities)
__________________________________________________________________________________________
__________________________________________________________________________________________
Home remedies
__________________________________________________________________________________________
__________________________________________________________________________________________
Health care resources
__________________________________________________________________________________________
__________________________________________________________________________________________
Health workers
__________________________________________________________________________________________
Health agencies
__________________________________________________________________________________________