FAMILY HEALTH ASSESSMENT/SURVEY TOOL

A.NAME OF THE BARANGAY

B.GENERAL INFORMATION
I.A.FAMILY DATA:

Name of the head of the family (father)

ARNULFO N. ARONCE
Birthday: July 29, 1970
Religion: Roman Catholic
Civil status: Married
Educational attainment: College Graduate
Age of as of last birthday: 51
Occupation: Musician

Name of spouse
VERONICA J. ARONCE
Birthday: December 22, 1970
Religion: Roman Catholic
Civil status: Single
Educational attainment: College Graduate
Age of as of last birthday: 50
Occupation: Nurse
Obstetrical Data: Optional:

B.Family Size
Large family (6 and above) _____
Medium (4-5) ___-__
Small (1-3) ____

II.Family members’ chart

Family Age Sex Civil Position in the Relationship Educational Occupation

members status family to family head Attainment
1. Jericho 14 M Single Son Student
Thomas J.
Aronce
2. Angeline 20 M Single daughter Student
Joy J. Aronce
3
4
5

A.Family Characteristics
1.Type of family structure

Extended ______ D. Patriarchal ____

Nuclear _______ E. Dominant family member _____
Matriarchal _____
ASSESSMENT:
a.Interview
1.Subjective Data:
Guidelines Questions:
1.Health Perception and Management
Healthy diet and healthy meals everyday
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2. Nutritional – metabolic
Fish and Vegetables
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3. Elimination-excretion patterns and problems

Hypertension
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____________________________________________________
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4. Activity exercise
Zumba and Jogging in the morning
____________________________________________________
____________________________________________________
____________________________________________________
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5.Sleep rest
Sleep at 8 pm and wake up at 5am
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6.Good sensory and auditory adequacy

____________________________________________________
____________________________________________________
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7. Self perception/self concept

____________________________________________________
____________________________________________________
____________________________________________________
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8.Role relationship
A mother and a father
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9. Sexuality reproductive
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10.Coping-stress tolerance
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11. Value-Belief Pattern

____________________________________________________
____________________________________________________
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2.Physical Assessment:ADULT

BODY PART/S METHOD NORMAL ACTUAL NURSING

USED FINDINGS FINDINGS IMPLICATION/S
I.SKIN
a.Color Inspection No
discoloration
b.Temperature Inspection Within Normal
Range
c.Turgor Inspection Skin pinches
easily and
immediately
returns to its
original
position
d.Other Inspection
Findings
II.HAIR
Inspection Varying
a.Distribution amount of
terminal hair
cover the
scalp
b.Texture Inspection Fine or thick
hair, silky
III.EYES
a.Symmetry Symmetrical
BODY PART/S METHOD NORMAL ACTUAL NURSING
USED FINDINGS FINDINGS IMPLICATION/S
b.Color Inspection No discoloration of
the Sclera
c.Eye Inspection Can follow moving
Movement object
d.Other inspection
Findings
IV.EARS
a.Symmetry Inspection Symmetrical
b.Auricles Inspection Align with the
corner of each eye
c.Other Inspection
Findings
V.NOSE
a.Symmetry Inspection Symmetrical
b.Sinuses Inspection Frontal and
Maxillary sinuses
are non tender to
palpate
c.Other Inspection
Findings
VI.MOUTH
a.Lips Inspection Symmetrical upon
movement
b.Color Inspection No discoloration
c.Teeth Inspection Free from decays,
white
Complete # of
teeth
d.Tongue Inspection Position:Centrally
located, no
protrusion of
tongue, no
drooling of saliva,
no signs of
dryness of the
mucous
membranes
Color: Pink

BODY PART/S METHOD NORMAL ACTUAL NURSING

USED FINDINGS FINDINGS IMPLICATION/S
VII.NECK
a.Movement Inspection Able to flex
and turn side
to side without
pain or
resistance, no
lymph nodes
b.Other Findings
VIII.CHEST/LUNG
S
a.Breathing Inspection Quiet,rhythmic
patterns and effortless
respirations,
Normal range
b.Symmetry Inspection Symmetrical
c.Shape Inspection Oval, Elliptical
d.Breath Sounds Inspection No
adventitious
sounds
IX.ABDOMEN
a.Shape Inspection Flat, Rounded
b.Umbilicus Inspection No discharge,
odor, redness
or herniation
C.Bowel Sounds Inspection Occurs every
10-30
seconds.
Sounds like
clicks, gurgles
or growls
d.Other Findings
X.UPPER
EXTREMITIES
a.Symmetry InspectionSymmetrical
b.Movement InspectionCan perform
ROM
c.Fingers Inspection Can perform
ROM
d.Nails Inspection Clean and
groomed; no
discoloration
of nail beds
BODY PART/S METHOD NORMAL ACTUAL NURSING
USED FINDINGS FINDINGS IMPLICATION/S
X.LOWER
EXTREMITIES
a.Symmetry Inspection Symmetrical
b.Movement Inspection Can perform
ROM
c.Gait Inspection
c.Fingers Inspection Can perform
ROM
d.Nails Inspection Clean and
groomed; no
discoloration of
nail beds
XI.BACK
a.Symmetry Inspection Symmetrical
b.Shape Inspection
Note: For Post Partum Client
d.2.POST PARTUM ASSESSMENT

BODY PARTS METHOD NORMAL ACTUAL NURSING

USED FINDINGS FINDINGS IMPLICATIONS
No
I.BREASTS tenderness,
no
engorgement,
presence of
colostrum
a.Other Findings
Well
II.UTERUS contracted,
minimal
vaginal
bleeding; no
fouls smelling
lochia &
based on the
number of
days of
delivery
a.Other Findings

For infants:
Head Circumference:
Chest Circumference:
Abdominal Circumference:
Length:
Weight:
Umbilical Status:
Other Findings:

Other Measures: for nutritional Assessment

BMI-Body Mass Index
Formula: BMI=kg/m2
Kg =person’s weight in kg and m2 is the height in
meters squares

C.SOCIO ECONOMIC PROFILE

I.LANGUAGE SPOKEN (DIALECT) ____

TAGALOG__-___
ILOCANO_____
KAPAMPANGAN_____
PANGGALATOK_____
VISAYA ______

II. HOUSING
CONCRETE _____
WOOD AND CONCRETE ___-__
NIPA AND BAMBOO_____
ALL WOOD_____
SHANTY_____

III. LAND OWNERSHIP

Owned ___-__ Rented_____ others; specify _____

IV. Power Energy Source

Lighting
Electricity ___-__ kerosene lamp _____ LPG lamp_____
Cooking
LPG___-__ Charcoal _____ Electric range _____ Wood and others_____

V. Appliances Owned
Cellphone___-__ TV___-__ Radio__-___ Refrigerator___-__
Computer__-___ Aircon___-___ Electric Fan___-__ Computer __-___

Other; specify_____

VI. Transportation Availed

Tricycle__-___ Passenger Jeepney_____ Private Car/ Van__-___
Paasenger Bus_____ Others; specify: _____

VII. Monthly family income source

Husband ______________
Wife _________________

Monthly Family Income Amount (Check bracket)

_____Below P5,000.00 _____Above 20,000 – 30,000.00

_____Above 5,000.00 – 10,000 _____Above 30,000 – 40,000.00

_____Above 10,000 – 15,000.00 __-___Above 40, 000 – 50,000.00

_____Above 15,000 – 20, 000 _____More than 50,000.00.

D.ENVIRONMENTAL HEALTH INFORMATION

A. Drinking water supply:

Source:
 Deep well ( 3 pipes and above) Shallow well ( below 3 pipes)
 owned  owned
 shared  shared
Mineral Water
 Open well  Others; specify: _______________
 owned  owned
 shared  shared
 Nawasa
 owned
 shared

B. Garbage Disposal
Burning____ Composting ______
Segregation_-___ Dumping______
Others; specify: _______________

C. Drainage
Open __-__
Closed_____
None_____

D. Toilet Facilities

1.Sanitary toilet:

 Flush  Buhos
 owned  owned
 shared  shared

2. Unsanitary toilet:
 Antipolo type
 owned
 shared

3. None/No toilet:

E.Health information

A. Common diseases encountered from the past 2 years (leading causes morbidity)
____Hypertension
_____
__________
__________
__________
__________

B. Common causes of death from the past 2 years (leading causes of mortality)
____None_____
_________
_________
_________
_________

C Child bearing mothers (15-49 years old)

a. number of pregnancy: __________G

b. number of children born a live: __________L
c. number of infant born dead: __________P
d. number of abortion: __________A
e. last delivery attended by: __________
f. data on pregnancy: __________
(Pregnant mothers)

D. Family Planning Methods Used:

A. Natural Method
 BBT  LAM method  Symphothermal method
 Cervical mucous method combination of BBT and CMM

B. Artificial Method
 Pills  Condom  spermicidal
 BTL  Vasectomy  DMPA
 copper-T
C. Others; specify______

C.Feeding Practices of Lactating Mothers

_____ Breast feeding

_____ Bottle Feeding
_____ Mix Feeding

D.Immunization (0-12 months) Provided by: (Health facilities; specify)

BCG  ____________________

DPT1  ____________________

DPT2  ____________________

DPT3  ____________________

OPV1 ____________________

OPV2 ____________________

OPV3 ____________________

Hepa. B1  ____________________

Hepa. B2  ____________________

Hepa. B3  ____________________

Measles  ____________________

E. Nutritional status (0-72 months)

Name Age Birthday Weight Date of OPT

         
         
         
         
F. Food
1. Source:

 Market  Store  Vendor  Own produced

2. Selection:

 Fresh  Preserved  Others; specify: _______________

G.Health Resources Commonly availed by the family

1. Hilot/Herbularyo_____ 4. District hospital _____

2. Barangay Health Center _____ 5. Private hospital/clinic __-___
3. Rural Health Unit _____ 6. Others; specify_____

E. Awareness of community Organization

A.Are you aware of existing organizations in the community?

_____ Yes _____ No

B. Name all the organizations you know.

______________________________________________________________________
______________________________________________________________________

C.Are you a member of any of these organizations?

_____ Yes _____ No

D.Are you aware of its activities and projects?

_____ Yes _____ No

E.How are you involved in its activities?

_____ attend meetings _____ give donations
_____ planning _____ evaluation
_____ implementation _____ others, specify __________

F.Name 5 formal and non formal leaders of the community whom you think can lead the
people
1. ____________________________
2. _____________________________
3. _____________________________
4. _____________________________
5. _____________________________
Surveyed by:

Name of Student: Angeline Joy J. Aronce Name of C.I.

___________