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FAMILY HEALTH ASSESSMENT

Head of the Family: ____________________________________________________________ Date: ______________________________________

Address (includes important landmark) : ___________________________________________________________________________________________________

I. ASSESSMENT OF THE FAMILY

A. Members of the Household

Birth Date Occupation

Relation to Marital Highest `Immunization Physical
Name Sex Age Type of
Head Month Year Status Education Place Status Health
Work

B. Type of Family Form:

C. Cultural and Religious Orientation:

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D. Social Class Status
1. Breadwinner: _________________________________________
2. Average Monthly Family Income: _________________________

E. Recreational or Leisure Time Activities: _________________________________________________

___________________________________________________________________________________

II. PHYSICAL ENVIRONMENT

A. Home
1. Ownership ( ) Owned ( ) Rented ( ) Others ____
2. Construction materials used ( ) Light ( ) Mixed ( ) Strong
3. Number of rooms used for sleeping: _______________________
4. Specific room for: ( ) Kitchen ( ) Dining
5. Furniture: ( ) None ( ) Limited ( ) Adequate
6. Home appliances present: ______________________________________________________
7. Lighting Facilities: ( ) Electricity ( ) Kerosene
( ) Others, specify ______________________________________
8. Safety Hazards: ( ) Loose, rickety stairs ( ) Loose doors, walls, post
Windows: ( ) None ( ) only 1 ( ) more than 1
Sharps and matches within reach of children? ( ) Yes ( ) No
Soft drinks bottles used as kerosene container? ( ) Yes ( ) No
Medicine and poisonous substances kept side by side? ( ) yes ( ) No

B. Kitchen
1. Cooking Facility: ( ) Electric stove ( ) Gas Stove ( ) Firewood / Charcoal
2. Sanitary Condition:
Drainage Facility: ( ) Open Drainage ( ) Closed Drainage

C. Water Supply
Please indicate water source by placing a check mark in the appropriate column.

Source Public Private

1. Natural Spring
2. Electric Water Pump
3. Open well (tabay)
4. Piped system
5. Artesian well (bomba)

1. Distance from the house: _______________________________________________ (m) tabay

2. Collection containers:
Container With Cover Without Cover
a. Bottles
b. Cans
c. Pails
d. Others

3. Storage
Container With Cover Without Cover
a. Jar (banga) with faucet
b. Jar (banga) without faucet
c. Can
d. Pitcher
e. Pail
f. Others
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D. Waste Disposal
1. Toilet
a. Type:
Type Owned Shared
Open pit privy
Bore-holed latrine
Antipolo system
Pail system
Closed pit privy
Overhung latrine
Flush type
Water – sealed
Other (specify)

b. Distance from the house : __________________________________ (m)

c. Sanitary conditions (describe) _____________________________________________________
_______________________________________________________________________________

2. Refused and Garbage

a. Container
Type Owned Shared
Plastic
Can
Sack
Steel Drum
Other (describe)

( ) No container used

b. Method of Disposal
( ) Hog feeding ( ) Open dumping ( ) Burning
( ) Buried in pit ( ) Composting ( ) Motorized collection system
( ) Other, specify __________________________________________________________

E. Domestic Animals
Kind Number Where Kept

F. Community in General
1. Type of Community
Residential Area Industrial Area
Rural
Urban
Suburban

2. Accessible to: (Encircle)

a. Transportation YES / NO
b. Church YES / NO
c. School YES / NO
d. Market YES / NO
e. Shopping Center YES / NO
f. Health Agency YES / NO
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3. Congested Neighborhood: ____________________________________________________________

4. Recreational facilities present: _________________________________________________________
5. Health Care facilities present: _________________________________________________________
6. Distance of the house to the nearest care facilities: ______________________________________(m)
7. Family’s perception of this community: __________________________________________________
8. Family’s association transactions with the community:
a. What community services does the family usually utilize?
_____________________________________________________________________________
b. Who in the family uses these community services?
_____________________________________________________________________________
c. Frequency of community service utilization:
_____________________________________________________________________________
d. Family’s perception of the agency from whom it receives assistance:
_____________________________________________________________________________

III. PSYCHO-SOCIAL ENVIRONMENT

A. Family Strengths and Weaknesses:
Strengths _____________________________________________________________________
_____________________________________________________________________________
Weaknesses __________________________________________________________________
_____________________________________________________________________________

B. Family Communication
1. Usual patterns: ( ) Wheel ( ) Isolate ( ) Chain ( ) Switchboard
2. Purposes:

3. Rules observed during interactions:

C. Family Stage of development

1. Present stage:

2. Developmental tasks demonstrated by the family at the present stage:

D. Role Structure
Family Member Formal Role Informal Role

E. Power Structure
Decision to be made Decision Maker Decision-Making Process
1. Major family purchases
2. Daily household expenses
3. Child-rearing practices
4. Social activities
5. Household activities
6. Discipline
7. Health-illness matters
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Over-all power typology

( ) Chaotic (leaderless) Family
( ) Egalitarian (shared power) Family
( ) Syncretic (mutual commitment)
( ) Atomistic (autonomic or independent commitments)
( ) Autocratic
( ) Husband-dominated family
( ) Wife-dominated Family

F. Family values
1. Identified and practical moral values

2. How do these family values affect the health status of the family?

G. Family Coping Functions

1. Short-term stressors

2. Long-term stressors

3. Family strengths which counterbalance stressors

4. Functional, coping strategies utilized by the family (past and present)

IV. HEALTH-RELATED BEHAVIORS

A. Family attitude towards:
1. Health: ______________________________________________________________________
______________________________________________________________________________
2. Illness: ______________________________________________________________________
______________________________________________________________________________

B. Health Care Facilities:

1. Usual Source of health care: _____________________________________________________
2. Frequency of visit to the health care facility: __________________________________________
3. Member of the family who usually utilizes health care services: __________________________
_______________________________________________________________________________
4. Means of financing health care: ___________________________________________________
5. Barriers to obtaining health care: __________________________________________________

C. Dental Health Practices:

D. Family Medical History:

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F. Family Drug Habits:

G. Nutrition
1. Dietary practice and food allergies

2. Food History Record

SAMPLE MENU FOR ONE DAY

MEAL FOOD SERVED QUANTITY INDIVIDUAL REFERENCES

3. Market Practices:

G. Sleep and Rest Practices

SLEEPING AIDS
FAMILY MEMBERS TIME FOR SLEEPING TIME FOR WAKING
USED, if any

V. FURTHER ASSESSMENT DATA NEEDED:

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Interviewer: ___________________________________________
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