University of San Jose-Recoletos

School of Allied medical Sciences

Nursing

FAMILY HEALTH ASSESSMENT FORM

Area Surveyed: _________________________________________

Head of the Family: _________________________________
Date Surveyed: _____________________________________

I. FAMILY PROFILE: Members of the household:

Relation to the Birthdate Occupation

Educational
NAME Head of the Age/Sex Marital Status Physical Health
Month Year Attainment Type Occupation
Family

A.. Type of Family form (nuclear or extended): _____________________________

B. Length of stay in the Area ( months or years): ____________________________
C. Place of Origin: ____________________________________________________
II. HEALTH STATUS

A. Maternal Reproductive History (For each pregnancy, please answer the following questions using the chart found below):

PRENATAL OUTCOMES SEX DELIVERY FAMILY PLANNING METHOD

MATERNAL
PREGNANCY YES (by Depo
AGE NO DIED ABORTED LIVING Attendant Place Pills IUD Others
whom) Provera

For pregnant mothers, please answer the following questions:

If currently pregnant: LMP: _________________________ EDC: _______________________________ AOG: _____________________________
B. Child Care (For each child 12 years old and below please answer the following questions using the table below):

IMMUNIZATION
NAME OF CHILD AGE WEIGHT HEIGHT Nutritional Level DPT (# of OPV ( # of AMV (# of HEP B (#
BCG OTHERS
dose) dose) dose) of dose)
 Usual Source of Vaccine: ( ) Governement ( ) Private Breastfeeding: ( ) yes ( ) no (specify the reason)_______________________________
1. Health Care
1. Is there any member of the family who is sick at present? ( )No ( )Yes What Illness? __________________________________________
2. Is there any member of the family who is disabled? ( )No ( )Yes What type of disability? __________________ Age: ___________
3. Where do you usually go for medical care? ( ) Private ( )Government Hospital ( )Private Doctor
( )Hilot ( )Relatives ( ) Barangay Health Worker ( ) Self ( ) Others (specify): ______________________________
4. Approximate distance from the house to the nearest health center? _____________

III. Physical Environment

A. Home
1. Ownership House ( ) owned ( )rental ( )others ___________________
Lot ( ) owned ( )rental ( )others ___________________
2. Number of rooms use for sleeping: ______________________
3. Construction material used: ( )Light ( )Strong ( ) mixed
4. Home appliances ( )television ( )radio ( )others: ______________________________________________________________________________
5. Drainage: ( )open ( )Close type
6. Safety Hazard: ( )loose rickety stairs ( )loose doors, walls, posts
Number of windows noted: ( ) only 1 ( ) more than 1
Presence of dangerous materials such as: ( ) sharp objects i.e. knife, scissors ( ) matches ( ) lighters
( ) corrosive liquids such as kerosene, insecticides ( ) medicines ( ) others (specify)
B. Water Supply
1. Sources: ( ) Level 1 ( ) Level 2 ( ) Level 3
2. Water decontamination: ( ) none ( )yes [ ]chlorination [ ] boiling [ ]others specify: _____________________
3. Approximate distance of the water source from the house: ___________________
4. Water ( )botelya ( )Balde ( )gallon ( )water jag ( )banga ( )others specify: ______________________

C. Toilet
Ownership: ( )owned ( )shared (please indicate the total number of persons sharing the facility) ______________________________
Type: ( )antipolo ( )open pit privy ( )water sealed ( )others specify:____________________________________
 D. Garbage disposal: ( ) open dumping ( ) burning ( )buried in a pit ( )collected by garbage truck ( )composting ( ) others specify:__________

IV. Socio Cultural

1. Are you a member if any civic organization: ( )No ( )Yes
2. Usual source of current information: ( )Radio ( )Newspaper ( )Neighbor
( )television ( )Other family members ( )Others specify:________________
3. What is the usual means of relaxation: ( )sports ( )gambling ( )sleeping ( )TV/movies ( )others:___________________
4. Please list any taboo/s that you may be able to extract the respondents in terms of health practices: ___________________________________________________________

V. Economics
SOCIAL CLASS STATUS
1. Breadwinner: __________________________________________
2. Average monthly family income: __________________________
3. Source of income/livelihood: ( )Business ( )Salary ( )Pension ( )Others:______________________________
4. Is your home enough for your basic needs (food, shelter clothing, health): ________________________________
5. Problems usually affecting the family: _________________________________________________________________________