FAMILY HEALTH CARE PROCESS

A. FAMILY PROFILE
Name of the family:
Address:
Members of the household:

Father’s Name: Age: Occupation:

Mother’s Name: Age: Occupation:
Children:
Name Age Position Occupation
1.)
2.)
3.)
4.)
5.)

 Type of family structure:

 Dominant family members in terms of decision making:

 General family relationship:

B. SOCIO-ECONOMIC AND CULTURAL CHARACTERISTICS

1. Income and Expenses:

Household Members Occupation Place of work Income

1.)
2.)
3.)
4.)
5.)

2. Adequacy to meet basic necessities:

3. Who makes decision about money and how it is spent?

Educational attainment of each member of the family:

Household Members Educational Attainment

1.)
2.)
3.)
4.)
5.)

Ethnic Background:
Religious Affiliation:

Relationships of the family to larger community:

C. HOME AND ENVIRONMENT:

D. HEALTH STATUS OF EACH FAMILY MEMBER:

E. VALUES AND PRACTICES OF HEALTH PROMOTION/MAINTENANCE AND DISEASE

PREVENTION:
Possessing Electrical Facilities: [ ] Yes [ ] No

ENVIRONMENTAL FACTORS:
Housing facilities:
Type of housing:
Ownership:
Adequacy of living space:
[ ] Concrete [ ] Light Materials
[ ] others, specify:
[ ] Owned [ ] Rented [ ] others, specify:
[ ] One room [ ] Three rooms
[ ] more than three rooms [ ] other, specify:

Water supply:
Sources: [ ] Faucet [ ] Artesian well [ ] Deep well
[ ] others, specify:
Storage: [ ] with cover [ ] without cover
[ ] others, specify:

Waste disposal:
Human waste disposal;
[ ] Antipolo [ ] Balot system (drop and throw) [ ] Water sealed
[ ] Cat hole [ ] Direct disposal in bodies of water: [ ] others, specify:

Refuse disposal: [ ] Burning [ ] composting [ ] Open pit

[ ] City’s garbage collecting system

Presence of rodents/ insects: [ ] Yes [ ] No

Sewage system: [ ] With septic tank [ ] covered canals [ ] Open canals

Presence of pollutants:
Air: [ ] Smoke from vehicles [ ] Odor from garbage/ stagnant water
[ ] Presence of factories

Water: [ ] Chemical/ toxic waste from factoris

[ ] Garbage throen into bodies of water

Land: [ ] Landfills
Noise source:

CULTURAL FACTORS:
Health seeking behavior: (First person to approach when family member got sick)
[ ] Family doctor [ ] Health center personnel
[ ] Hilots [ ] others, specify:
Health Practices: [ ] Hilots [ ] Quack [ ] Self Medication
[ ] Herbal medications [ ] hospital [ ] others, specify:
Personal habits/ practices:
[ ] Walking barefooted [ ] excessive smoking
[ ] Eating raw fish/ vegetable [ ] Frequent drinking of alcohol
 COMMUNITY SURVEY TOOL

HOUSEHOLD #: DATE INTERVIEWED:

INTERVIEWER/S:

1. COMMUNITY CORE:

Name:
Address:

Sex: [ ] Male [ ] Female

Civil Status: [ ] Single [ ] Married [ ] Widow [ ] Separated
Religion: [ ] Roman Catholic [ ] Islam [ ] Protestant
[ ] others, specify:
Dialect: [ ] Tausug [ ] Tagalog [ ] Ilokano
[ ] Chavacano [ ] Bisaya [ ] others, specify:
Family structure: [ ] Nuclear [ ] Kin Network [ ] Extended
[ ] others, specify:
Ethnicity: [ ] Tausug [ ] Tagalog [ ] Zamboangueño
[ ] Bisaya [ ] others, specify:

Age Group:

SEX
Male Female
0-28 days (Neonate)
29-1 year old (Infant)
1 year & 1 day-3 year old (Toddler)
3 year & 1 day- 6 year old (Pre-schooler)
6 year & 1 day- 12 year old (School age)
12 year & 1 day- 19 year old (Adolescent)
19 year & 1 day- 35 year old ( Early adulthood)
35 year & 1 day- 65 year old (Middle Adulthood)
65 year & above (Late Adulthood)

B. COMMUNITY SUBSYSTEMS

SOCIO-ECONOMIC FACTORS:

Educational Attainment:
[ ] Elementary [ ] High school [ ] College
[ ] Has not gone to school [ ] others, specify:

Employement Status:
[ ] Employed [ ] Unemployed [ ] Self-employed
[ ] Others, specify:

Occupation:

Monthly Income:
[ ] Below Php 1,000.00 [ ] Below Php 5,000.00
[ ] Below Php 10,000.00 [ ] Others, specify:

Communication facilities;
[ ] Telephone [ ] TV
[ ] others, specify:
HEALTH CARE DELIVERY SERVICES:

Health facilities: (Type of health facilities frewuently availed by the community.)

[ ] Hospital [ ] Private clinics
[ ] Health centers [ ] others, specify:

Health manpower: (Among the health personnel to whom do you always avail of health
services.)
[ ] Doctor [ ] Nurse [ ] Midwife
[ ] Trained hilot/ ‘BHW’ [ ] Sanitary inspector

Health status: Number of children immunized:

Fully immunized: Partially immunized: Not immunize:

Common illness experience by the family:

[ ] Cough colds [ ] Diarrhea
[ ] Fever [ ] Constipation

How often do you avail of the services?

[ ] Always [ ] Often
[ ] Sometimes [ ] Never

POLITICAL FACTORS:

Do the barangay officials consult the people regarding decision of major issues?
[ ] Yes [ ] No

Are barangay officials actively involved in the communitty health services?

[ ] Yes [ ] No

Are the officials responsive to the needs/ problems of the community?

[ ] Yes [ ] No

Do the barangat tanods watch over the safety of the community?

[ ] Yes [ ] No

Institution present:
[ ] Police station [ ] Hospital [ ] Health center
[ ] Recreational facilities [ ] Fire station