TAGUM DOCTORS COLLEGE, INC.

Mahogany Street Rabe Subdivision Tgaum City

Tel/ No. (084) 655-6971,09994759793
Email: tdci_007@yahoo.com

FAMILY CARE PLAN

Date Cues Health Family Nursing Goal of Care Objectives of Care Nursing Interventions Methods Resources Evaluation
Problem Problem Family/Nurse Contact

Submitted by: Submitted to:

Name of Student: ______________________________ Name of CI: ________________________________
Group # : _____________________________________ Date: _____________________________________

SecondSemester2022
TAGUM DOCTORS COLLEGE, INC.
Mahogany Street Rabe Subdivision Tgaum City
Tel/ No. (084) 655-6971,09994759793
Email: tdci_007@yahoo.com

ANECDOTAL REPORT

DATE/TIME OBJECTIVES: STRENGTHS AND WEAKNESSES LEARNINGS

Submitted by: Submitted to:

Name of Student: ______________________________ Name of CI: ________________________________
Group # : _____________________________________ Date: _____________________________________

SecondSemester2022
TAGUM DOCTORS COLLEGE, INC.
Mahogany Street Rabe Subdivision Tgaum City
Tel/ No. (084) 655-6971,09994759793
Email: tdci_007@yahoo.com

FAMILY SERVICE AND PROGRESS RECORD

HEAD OF THE FAMILY: ____________________________________________________________ FAMILY NUMBER: _______________________________________

ADDRESS: ___________________________________________________________________________________________________________________________________

I. Assessment of the Family, Home and Environment Conditions:

A. Members of the Household

FAMILY MEMBER RELATION SEX BIRTHDAY MARITAL EDUCATIONAL OCCUPATION REMARKS

TO HEAD STATUS ATTAINTMENT
No. Name Month Year Type of Work Place
B. Home and Environment
Date Assessed: _____________________________
1. Home
a. Ownership: ( ) Owned ( ) Rented ( ) Rent-Free
b. Construction materials Used: ( ) Light ( ) Mixed ( ) Strong
c. Number of rooms for sleeping: ________________________________
d. Lighting facilities: ( ) Electricity ( ) Kerosene ( ) Others: Specify: ____________________
e. General Sanitary Condition: ___________________________________________________________________________________________________
__________________________________________________________________________________________________________________________

2. Drinking Water Supply

Source: ( ) Private ( ) Public Potability: ____________________________
Distance from House: ________________________________________________
Storage: ( ) None – Direct from faucet
( ) large covered container with faucet
( ) large uncovered container without faucet
( ) others, specify __________________________________________

3. Kitchen
Cooking Facility: ( ) electric stove ( ) gas stove ( ) firewood/charcoal
Sanitary Condition: ________________________________________________________________________
Drainage Facility: ( ) open drainage ( ) blind drainage ( ) None

4. Water Disposal
a. Refuse and garbage
Container: ( ) Covered ( ) Open ( ) None
Method of disposal:
( ) hog feeding ( ) Open burning
( ) open dumping ( ) garbage collection
( ) burial in pit ( ) others, specify: ___________________________________
b. Toilet
Type: ( ) none ( ) pail system
( ) overhung latrine ( ) Antipolo
( ) open pit privy ( ) water-sealed latrine
( ) closed pit privy ( ) flush type
( ) bored-hole latrine
 ( ) others, specify: _______________________________________________________
Distance from the house: ______________________________________________________________
Sanitary Condition: ___________________________________________________________________

5. Domestic Animals:

Kind Number Where Kept

6. The Community in General:

a. General Sanitary Condition:
b. Housing Congestion: ( ) Yes ( ) No
c. Presence of Breeding sites of vectors of Diseases:
( ) Yes; Specify: __________________________________________________
( ) None
d. Recreational Facilities: _____________________________________________________________________________________________
e. Availability of health care services (describe briefly) : ____________________________________________________________________
_______________________________________________________________________________________________________________
f. Distance of house from nearest health care facility: _____________________________________________________________________
________________________________________________________________________________________________________________