FAMILY HEALTH ASSESSMENT FORM

Respondent:   ALYSSA CHRISTINE M. KUMAR  ; Age: 19 Y/O 

Sex: FEMALE   Relation to Head:  DAUGHTER (If not the Head of the Family)

I. Family Data
A. Head of the family:   SURESH KUMAR     Age:   56 Y/O

B. Name of Spouse: MELANI M. KUMAR      Age:  52 Y/O

C. Address: CASANTIAGOAN NORTE LAOAC, PANGASINAN 

Household Elementary Elementary High School High College College

School
Member (Undergrad) (Graduate) (Undergrad) (Undergrad (Graduate)
(Graduate) )
MOTHER 

FATHER 
ELDEST DAUGHTER 

YOUNGEST 
DAUGHTER
D. Educational Attainment

A. Length of Residency:  19 Years  

B. Ethnic Origin:  Unsure

C. Family

Nuclear (   ✔    )                       Extended (       )

D. Religion

Roman Catholic (  ✔   ) INC   (      )

Jehovah’s Witnesses (     ) Adventist   (     )

Other:__________________ 
 E. No. of Children: 2 
 
II. Socio-economic Data

A.

Name Relation to Age Sex Status Education Occupation

Head
Suresh Kumar Head of the 56 M Married College undergraduate Protective
family  Officer
Melani M. Kumar Spouse 52 F Married College Graduate Midwife

Alyssa Christine M. Daughter 20 F Single College Undergraduate N/A

Kumar
Reshsa Mae M. Daughter 16 F Single High School N/A
Kumar  Undergraduate

B. Occupation:

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 (    ✔    )

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

2. Common fare rice and egg   (   ✔    ) rice and sardines

(       ) rice and noodles (       ) Others________________

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:  3 Bedrooms

4. Ventilation:
poor (    ) good (   ✔  )
5. Lighting Facilities: electricity (    ✔   )
kerosene (      )
others:_______________
6. General Surroundings:
clean     (   ✔     ) dirty (      )

Sanitary Observations: Presence of old tires that can be a site of mosquito

reproduction during rainy season

B. Source of Water Supply

artesian well (      ) deep well ( )
NAWASA (    ✔   ) others:_______________

C. Storage of Drinking Water

refrigerated (      ) uncovered (      covered   (    ✔ 
) )

D. Appliances

refrigerator ( ✔   ) stove   (  ✔  )

electric fan (  ✔  ) TV   (  ✔  )

E. Kitchen
electric stove (     )  gas stove  (   ✔   )
Firewood/charcoal (  ✔   )
    
F. Drainage
open ( ✔   ) blind (     ) none (    )
G. Containers Used
plastic  (   ✔  ) jars (  ✔   )
bottles  (  ✔   others:______________
)

H. Toilet Facilities
Sanitary:
flush  (  ✔   ) pit privy  (    )
shared (     ) owned    (   ✔  )
others: _______________ 

Waste Disposal: collection ( )

burning ( ✔ ) burying (✔)
open dumping   (     )
garbage cans  (   )
others:______________

I. Food Storage
Covered (✔ ) refrigerated  (      uncovered (     )
)

K. Presence of Animals
dogs(  ✔   ) cats (   )
pigs (     ) others:________________
L. Backyard Gardening:
vegetables  ( ✔   ) herbal   (  ✔   )
fruit-bearing   (  ✔  ) others:______________
M. Consultation
health centre   ( ✔  ) hilot      (     )
hospital (  ✔ )
N. Transportation
tricycle (  ) pedicab  (   )
walking (  ) jeep     (  )
Bicycle (   )           others: car

O. Community Observation
A. Sanitary Condition: Clean garbage bins are present around the
town

B. House Overcrowding/ Congestion Yes (    ) No (  ✔  )

C. Presence of breeding sites of vectors:  Yes   (  ✔  ) No (    )

If yes, specify:  presence of canal, stagnant water in some dark places and
bushy surrounding 
D. Health facilities: Health centre

E. Recreational facility:  basketball court

F. Distance of house to the nearest health care facility: walking

distance

The family members are healthy and with ability to provide family needs.
Based on the assessment the surrounding, and presence of animals
may cause medical problems if not handled properly. Foreseeable crisis
if the canal and bushes were not cleaned or not handled properly they
can be a site for mosquito reproduction and may cause in increase of
dengue cases.