Family Genogram

44 years old 50 years old

Rice & corn Farmer Sari-sari store vendor
Had tuberculosis (Year 2015), Has Had Tuberculosis (Year 2019)
lung mass and annual check-ups Alcohol Consumption: Rarely to Occasional.
( Since 2015) Doesn't smoke.
Doesn't consume alcohol (Eversince
diagnosed with TB).
Undiagnosed Hypertension
Doesn't Smoke

Edwin D. Baldeo Ophelia P. Baldeo

20 years old
Currently in 2nd year of Nursing.
Had childhood asthma.
Doesn't smoke nor consume alcohol.

Janna Vivien P. Baldio

 Family Eco Map

Church
Physician Market

Online
market riders Friends

Baldeo
Family Bills
Costumers Payment
Facilties

Relatives/
Health
Extended family
Services

School Mall
Family Assessment Guide

FAMILY HEALTH ASSESSMENT FORM

Respondent: Baldio, Janna Vivien P. Age: 20

Sex: Female

Relation to Head: Child ( If not the Head of the Family )

I. Family Data
A. Head of the family: Ophelia P. Baldeo Age:50

B. Name of Spouse: Edwin D. Baldeo Age:44

C. Address: Baranggay Bocboc San Carlos City, Pangasinan

D. Educational Attainment

Member of Elementary High School Senior High College

Schoool
Household

Mother Graduated Second year High

school

Father Graduated Second year High

School

Child Graduated Graduated Graduated Current: Second

year

E. Length of Residency: 7 years

F. Ethnic Origin: Pangasinense, Cebuano

G. Family

Nuclear ( / ) Extended ( )

H. Religion

Roman Catholic ( / ) INC ( )

Jehovah’s Witnesses ( ) Adventist ( )

other:

I. No. of Children: 1
II. Socio-economic Data

A. Source of Income
Husband:
 Employed ( / ) Unemployed ( )
Wife:

Employed ( / ) Unemployed ( )
Joint Monthly Income

Below ₱2,000 ( ) ₱3,000 - ₱5 ,000 ( / )

₱5,000 - ₱8,000 ( ) more than ₱8 ,000 ( )
B. Basic Expenditures
1. Food Daily
below ₱50 ( ) ₱50 - ₱75 ( )

more than ₱75 ( / )

2. Clothing: number of times of buying in a year

once ( ) twice (/)

thrice ( ) more than four times ( )

3. Housing
water (/) electricity ( / )

cellphone load (/)

4. Schooling
public ( ) private ( / )

5. Others

C. Nutrition
1. Food preference
fish ( ) fruit/vegetables ( ) meat ( ) mixed ( /)

III. Housing and Environmental Condition

A. Home
1. Type of Housing
concrete ( ) wood ( )
mixed ( / ) makeshift ( )
2. Ownership
owned ( ) rented ( )

rent-free ( /) others:

3. Number of rooms for sleeping: 2 rooms

4. Ventilation :
poor ( ) good( /)

5. Lighting Facilities :
electricity ( / ) kerosene ( ) others:

6. General Surroundings : clean ( / ) dirty ( )

Sanitary Observations:

B. Source of Water Supply

 artesian well ( ) deep well ( )
NAWASA ( ) Others: POSO
C. Storage Drinking Water
refrigerated ( ) uncovered ( covered ( / )

D. Appliances

refrigerator (/ ) stove (/)

electric fan (/ ) TV (/)

E. Kitchen
electric stove ( ) gas stove ( / )
Firewood/charcoal ( )

Drainage
Open ( ) blind ( )

None ( /)

Sanitary observations: Water are absorbed by soil

F. Containers Used

plastic ( /) jars ( )
bottles ( ) others:
G. Toilet Facilities Sanitary:

flush ( ) pit privy ( )

shared ( ) owned (/)
others:

Unsanitary:

“ballot” system ( / ) others:

H. Waste Disposal
collection ( ) burning ( / )
burying ( ) open dumping ( )
garbage cans ( ) others:

I. Food Storage
covered ( / ) uncovered ( )
refrigerated ( / )

J.Presence of Animals
dogs( / ) cats ( )
pigs ( ) others: Cows, goats, geese,
K. Backyard Gardening: chickens, bird, snake.

vegetables ( / ) herbal ( / )
fruit-bearing ( / ) others:

L. Consultation
health center ( / ) hilot (/ )
hospital (/)
M. Transportation
 tricycle (/) pedicab ( )
walking () jeep ( /)
bicycle ( )

N. Community Observation
a. Sanitary Condition: Good
b. House Overcrowding/ Congestion Yes ( ) No ( / )
c. Presence of breeding sites of vectors: Yes ( ) No ( / )
If yes, specify:

d. Health facilities: Rural Health Unit

e. Recreational facility: None
f. Distance to the nearest health care facility: 10 minutes away

Evaluation
Stress point or
foreseeable crisis
Health Threats Health Deficit
 Not so high  Undiagnosed  Hospitalization
quality materials Hypertension.  Financial Crisis
of the house.  Cough  Mental health
 Covid 19 problems
 Unvaccinated
 Illness
 Emotional health
problems