Wife: ( )Employed ( )Unemployed ( )Self employed

Mountain View College

School of Nursing C. Joint Monthly Income:
( )Below Php 2,000 ( )Php 3,000-Php 4,999 ( )Php 5,000-Php 10,000
FAMILY HEALTH ASSESSMENT FORM ( )Php 10,000-Php 15,000 ( )More than Php 15,000
D. Basic Expenditures:
Respondent _________________________________Age__________Gender____________ 1. Food daily: ( )Below Php 50 ( )Php 50-75 ( )More than 75
Family Stage____________________________ Relation to Head______________________ 2. Clothing: Number of times of buying in a year
I. Family Data: Family Structure, Characteristics & Dynamics ( )Once ( ) Twice ( )More than 4 times
A. Head of the Family_________________________________________Age___________ 3. Housing: ( )Water ( )Electricity ( )Cellphone Others_____________
B. Name of Spouse__________________________________________ Age___________ 4. Schooling ( )Public ( )Private
C. Address _________________________________________Tel No. ________________ 5. Others:_______________________________________________________
D. Educational Attainment: Husband ___________________________________________ E. Nutrition:
Wife _______________________________________________ 1. Food Preferences: ( )Fish ( )Fruits/Vegetables ( )Meat ( )Mixed
E. Length of residency_______________________________________________________ 2. Common Fare: (24 hours, or 6 weeks to 6 months food recall)
F. Ethnic Origin: Husband ______________________ Wife_________________________ ( )Rice & egg ( )Rice & sardines ( )Rice & Noodles ( )Others____________
G. Family Type:( )Patriarchal ( )Matriarchal ( )Nuclear ( ) Extended ( )Others (specify)____ F. Nutritional status of children below 12 years old:
H. Number of Children______________________________________ Name Date of Birth Weight Height Nutritional
I. Dominant family members in terms of decision making, especially in matters of health Status
care: __________________________________________
J. General family relationships/Dynamics:
a. Presence of any obvious/readily observable conflict between members
b. Characteristics communication/interaction patterns among members
K. Members of the household:
Name Relation to Head Age Gender Civil Educational Occupation
Status Level

III. Housing and Environmental Conditions

A. Home:
1. Living Space (measurement)___________________________________________
2. Sleeping arrangement________________________________________________
3. Presence of breeding or resting of insects, rodents or other vectors_____________
4. Presence of accident hazards
( )Beside the highway ( )Under the coconut trees ( )Stairs no handrails
II. Socio-economic Data & Cultural characteristics ( ) Children (1-10 years old) left alone in the house
Occupation Place of Work Income Adequacy to meet Basic ( ) Others ( Specify________________________________________________
necessities 5. Cooking facilities: ( ) Electric ( )Gas Stove ( ) Butane ( )Earthen ( ) Others__________
Father: Yes:______ No ____ 6. Type of Housing: ( )Concrete ( )Wood ( )Makeshift ( )Mixed[describe]___________
Mother: Yes ______ No ____ 7. Ownership: ( )Owned ( )Rented ( )Rent free ( )Others_____________
2.Who makes decision about money and how it is spent? ________ 8. No. of Rooms for Sleeping: _______
3. Significant other/s_____________________ 9. Ventilation: ( )Good ( )Poor
Roles they play in family life: (a. ) (b.) 10. Lighting Facilities: ( )Electricity ( )Kerosene ( )Chargeable Light ( )Others________
4. Relationships of the family to larger community: 11. Toilet facility: ( )Type ( )Pit Privy ( ) Antipolo ( ) bore hole latrine ( )Water sealed
A. Source of income:____________________________________________________ Ownership____________Sanitary Condition____________
B. Occupation: 12. Drainage system Type: ( )Open ( )Closed ( )No Drainage
Husband: ( )Employed ( )Unemployed ( )Self employed 13. Garbage Disposal Type: ( )burning ( )Compost pit ( )open ( )Sanitary condition
 ( )Others
14. Presence of Animals __________________________________________________ Hospitalized –
15. Backyard Gardening ( )Vegetables ( ) Herbal ( ) fruit trees ( )Others____________ 5. Where-
Not-
14. General Surroundings: ( )Clean ( )Dirty Sanitary Observations_________________ Dx-
15. Water Supply: ( )Artesian ( )Deep Well ( )NAWASA ( )Others________________
2.
16. Storage of Drinking Water: ( )Refrigerated ( )Covered ( )Uncovered ( )Others _____ |Beliefs and Practices related to health and illness
17. Food Storage : ( )Covered ( )Uncovered ( ) Others___________________________ a.__________________________________________________________________
E. Community Observation: b.__________________________________________________________________
1. Kind of neighborhood: ( )slum area ( )rural ( )urban ( ) congested c.__________________________________________________________________
2. Sanitary condition:________________________________________________
3. Presence of breeding sites of vectors/insects:____________________________ 3. Nutritional assessment (especially for vulnerable or at-risk members)
4. Health Facilities :__________________________________________________ a. Anthropometrics data (children): Weight in kgs. Height in ft. & inches
5. Distance of House to nearest Health Facilty______________________________ Upper arm circumference__________________________________
6. Social Facilities____________________________________________________ b. Dietary history indicating quality and quantity or food intake per day (usual food) eaten for
past few weeks)or 24 hour food recall.
7. Recreational Facilities:______________________________________________ _____________________________________________________
8. Communication Facilities____________________________________________ _____________________________________________________
9. Transportation Facilities_____________________________________________ c. Eating/feeding habits/practices
IV. Health Status/ condition between meals ___ junk foods ___amount of water intake per day _______
1. Status of Each Family Member: ____________________________________________________________
Medical History & Hereditary Past Illnesses Medications Taken/Treatment 4. Physical assessment indicating presence illness states (diagnosed or undiagnosed by medical
Diseases Done practitioner___________________________________________________
Father Hospitalized – ___________________________________________________________________
Where- 5. Laboratory/diagnostic results____________________________________________
Not- ___________________________________________________________________
Dx- V. Values, Practices of Health Promotion/Maintenance and Disease Prevention
1. Use of preventive health services
Mother Hospitalized –
a. Immunizations__________ ___________ ____________ __________
Where-
b. Exercises
Not-
Dx- c. Proper diet
d. Stress management
Children e. Smoking: yes_______ no ______ how many ___________
Hospitalized –
1. Where- f. Drugs: yes ______ no ______ what kind ___________
Not- g. Alcoholic drinks: yes ________ no ____________
Dx- h. Sleep and rest: what kind-
Nap after lunch: yes _________ no ________
2. Hospitalized – Number of hours of sleep -
Where-
Not-
Dx- FAMILY HEALTH PROBLEMS
3. Hospitalized –
Where-
Not-
Dx-

4. Hospitalized –
Where-
Not-
Dx-