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Family Health Assessment 2
Family Health Assessment 2
Family Health Assessment 2
1. IDENTIFICATION INFORMATION
Head of Family: Arman Abordo
Ethnicity: Asian
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: 1 ½ kg.
Milk: Quantity used per day: half to whole liters
Non-vegetarian dish: Specify: Chicken, Fish, Beef, Meat, Junkfoods How often: 2 – 3x per week
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 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? Hospital, if necessary.
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?
March 2021. For what reason: Urinary Tract Infection & Toncilitis
d. When was the last time you or any of your family member visit a dentist? February 2021.
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
Prepared by: