FAMILY SERVICE AND PROGRESS RECORD

HEAD OF THE FAMILY __________________________________ FAMILY NUMBER: _____________________________

ADDRESS: _________________________________________________________________________________________

I. Assessment of the Family, Home and Environmental Conditions:

A. Members of the Household

RELATION S HIGHEST REMARS/

MARITAL
FAMILY MEMBER TO THE E BIRTHDATE EDUC OCCUPATION DATE
STATUS
HEAD X COMPLETED ENTERED
No Name Month Year Type of Place
work
1
2
3
4
5
6
7
8
9
10

B. Home and Environment

Date Assessed: ____________________________________________________
1. Home
a. Ownership ( ) Owned ( ) Rented ( ) Rent-Free
b. Construction Materials used: ( ) Light ( ) Mixed ( ) Strong
c. Number of rooms for sleeping: __________________________
d. Lighting facilities ( ) Electricity ( ) Kerosene ( ) Others Specify
e. General sanitary condition: ___________________________________________________
___________________________________________________
2. Drinking water supply
Source: ( ) Private ( ) Public Potability: ________________________________________
Distance from house: __________________________________________________________
Storage: ( ) None (Direct from faucet or pipe)
( ) Large covered container with faucet
( ) Large uncovered container without faucet
( ) Others, Specify ____________________________________________________
3. Kitchen
Cooking facility: ( ) Electric stove ( ) Gas Stove ( ) Firewood/charcoal
Sanitary condition: ___________________________________________________________
Drainage Facility: ( ) Open drainage ( ) Blind drainage ( ) None
4. Waste Disposal
a. Refuse and Garbage
Container: ( ) Covered ( ) Open
Method of disposal:
( ) Hog feeding ( ) Composting
( ) Open dumping ( ) Open burning
( ) Burial in pit ( ) Others, specify: _________________________
b. Toilet
Type: ( ) None ( ) Pail system
( ) Overhung latrine ( ) Antipolo
( ) Open pit privy ( ) Water sealed latrine
( ) Closed pit privy ( ) Flush type
( ) Bored-hole latrine
( ) Others, specify: ______________________
Distance from house: ______________________________
Sanitary condition: ________________________________
5. Domestic Animals:

KIND NUMBER WHERE KEPT

6. The Community in General

a. General sanitary condition: ____________________________________________________
b. Housing congestion: ( ) Yes ( ) No
c. Recreational Facilities: ________________________________________________________
d. Availability of health care services (describe briefly): ________________________________
___________________________________________________________________________
e. Distance of house from nearest health care facility: _________________________________
___________________________________________________________________________
II. Problem Sheet

HEALTH CONDITIONS SUPPORTING DATA DATE

NURSING PROBLEMS
AND PROBLEMS CUES IDENTIFIED RESOLVED

III. Nursing Care Plan

HEALTH CONDITIONS EVALUATION

AND PROBLEMS AND OBJECTIVE OF NURSING PLAN OF OUTCOME
METHOD /
FAMILY NURSING CARE INTERVENTION CRITERIA/
TOOLS
PROBLEMS INDICATORS
IV. Service and Progress Notes

NURSING INTERVENTIONS, ACTIONS AND

DATE NURSING PROBLEMS SIGNATURE
PROGRESS