FAMILY HEALTH ASSESSMENT FORM

Respondent: _________________________________ Age: ___________

Civil status: _________________________________ Sex: ___________

Relation to Head: _____________________________ (If not the Head of the family)

I. FAMILY DATA

A. Head of the Family _______________________ Age _____

B. Name of Spouse __________________________ Age _____
C. Address _________________________________ Mobile No. ___________________
D. Educational Attainment
i. Husband ______________________
ii. Wife ______________________
E. Length of Residency ____________________
F. Ethnic Origin __________________________
G. Family
Nuclear ( ) Extended ( )

H. Religion
R/C ( ) Protestant ( ) Islam ( )

I. No. of Children ___________________

J. Member of Household

NAME AGE SEX STATUS EDUCATION OCCUPATION

II. SOCIO-ECONOMIC STATUS

A. Source of Income
Occupation
Husband _______________________________________
Wife ___________________________________________

Employed ( ) Unemployed ( )
Self-employed ( )

Monthly Income

Below P2,000 ( ) P2,000 – P5,000 ( )

P5,001 – p8,000 ( ) More than P8,000 ( )
 B. Family Expenditures
1. Food
Below P50 ( ) P50 – 75 ( )
More than P70 ( )

2. Clothing : number of times of buying

Once a year ( ) Twice ( )

Thrice ( )

3. Housing
Water ( ) Electricity ( )

Telephone ( )

4. Schooling
Public ( ) Private ( )

5. Others ____________________________________________________

III. HOUSING AND ENVIRONMENTAL CONDITION

A. Home

Type
Concrete ( ) Wood ( )

Mixed ( ) Makeshift ( )

Others ________________________

Ventilation:

Poor ( ) Good ( )

Lighting:

Adequate ( ) Inadequate ( )

Surroundings:

Clean ( ) Dirty ( )

B. Source of Water Supply

Artesian Well ( ) Deep Well ( )

NAWASA ( ) Others: _______________

C. Storage of Drinking Water

Refrigerated ( ) Covered ( )

Uncovered ( )

Container used:

Plastic ( ) Clay jars ( )

Bottles ( ) Others: _______________

D. Toilet Facilities
Sanitary
Flush ( ) Pit privy ( )

Shared ( ) Owned ( )

Others ______________________

Unsanitary:
Ballot system ( ) Others __________________

E. Garbage Disposal

Collection ( ) Burning ( )
Burying ( ) Open dumping ( )
Garbage cans ( ) Others _________________

F. Food Storage

Covered ( ) Uncovered ( )
Refrigerated ( )

G. Presence of Animals
Dogs ( ) Cats ( )
Pigs ( ) Others ____________________

H. Backyard Gardening
Vegetables ( ) Herbal ( )
Fruit bearing ( ) Others ____________________

IV. COMMUNITY RESOURCES

A. Health and Other Facilities

Health center ( ) Barangay Hall ( )

School ( ) Church ( )
Park ( ) Market ( )

B. Indigenous health worker

Trained Hilot ( ) BHW ( )

“Herbularyo” ( ) Untrained Hilot ( )
Others _____________

C. Sources of health funds :

Government ( ) Private ( )
NGOs/POs ( ) Others ______________
V. NUTRITION

A. Food preference

Fish ( ) Fruits/Vegetables ( )
Meat ( ) Others ______________

B. Common Fare

Rice and egg ( ) Rice and sardines ( )

Rice and noodles ( ) Others ______________

C. Presence of nutritional disorder

1. Goiter

Enlargement of the neck ( ) Dysphagia ( )

Hoarseness ( ) Others _________________

2. Anemia

Pallor ( )

Body weakness ( )

Easy fatigability ( )

3. Vitamin A Deficiency

Night blindness ( )

Pilak sa mata ( )

Others _____________

4. Others ___________________

VI. KNOWLEDGE, ATTITUDE, AND PRACTICE

A. Do you utilize the health center? Yes ( ) No ( )

If no, why? ________________________________________

B. Reason :

Illness ( ) Pre-natal ( )
Family planning ( ) Post-natal ( )
Dental ( ) Nutrition ( )

C. First person consulted in times of illness :

M.D ( ) Nurse ( )
Midwife ( ) “Hilot” ( )
 Herbularyo ( ) BHW ( )
Others ____________________

D. Usual illness in the family

__________________ ____________________

__________________ ____________________

__________________ _____________________

__________________ _____________________

What do you do for this condition?

Self-medication ( ) Consultation ( )
Hospital ( ) Private clinics ( )
Nursing ( )

E. Other Diseases

TB ( ) Leprosy ( )
Skin Disease ( ) Hepatitis ( )

F. Do you submit your children ( 0-12 months) for immunization? __________________

Name of child Birthday Immunization

BCG DPT OPV AM

G. Do you practice family planning? YES ( ) NO ( )

Method:
If no, why? __________________________________________

H. Method of Infant Feeding :

Breast ( )
Mixed ( )
Bottle ( )

I. Subjects you want to learn in health education :

Drug abuse ( ) Nutrition ( )

Family planning ( ) Herbal plants ( )
First Aid Measurement ( ) others _________________

Interview by : _______________________________
Date : _______________ Time : _____________