FAMILY ASSESSMENT GUIDE

Roxanne Yambot Champaca 2, Dicarma, Cabanatuan City

I. Demographic Data

Household number: 5

II. Family Data

Length of Residency: 7 years

Place of Origin: Cabanatuan

Family Size: 5

Religion: Husband – Catholic

Wife – Catholic

Family Member’s Chart

Family Members Age Sex Civil Status Position Relationship to Educational Occupation

in the Family Family Head Attainment

1. Roxanne Yambot 23 F Married Wife Spouse Elem. grad. Housewife

2. Roy Yambot 30 M Married Husband Spouse Elem. grad. Contractor
3. Rose Marie Yambot 5 F Single Eldest Child
4. Troy Yambot 4 M Single Middle Child
5. Rommel Yambot 2 M Single Youngest Child

III. Family Characteristics

D. Nuclear
Family Dietary Habits

What did you eat yesterday? (24 hours dietary recall)

Breakfast: Rice & Viand (Lutong Ulam)

Lunch: Rice & Viand (Lutong Ulam)

Supper: Rice & Viand (Lutong Ulam)

Monthly Family Income Source

Husband : ₱2,500

Wife :

Others :

Monthly Family Income Source

Total

Below ₱5,0000

Family Health Status/Health History

Father : None

Mother : None

Children: Cough & Colds

Felt Family Needs

1. Environmental Sanitation
2. Poor Hygiene
3. Poor Nutritional Status
IV. Home and environment

A. Is your lot owned?

No

B. Is your house owned?

Yes

C. Type of housing materials

Wood

D. Is the living space adequate? No

E. What are the appliances owned by the family? None.

F. Type of garbage disposal

Burning

G. Type of waste disposal

Flush

H. Type of drainage system

Open

I. Source of water supply

Shared

J. Drinking water storage

Covered

K. Containers used
Plastic containers

L. Food storage/cooking facilities

Covered

M. Common household pests found at home

Cockroaches & Mosquitoes
 N. Are there breeding sites of insects, rodents, etc. present? Yes

O. Pet/animals kept in the yard/home

Dog

P. Are there accident hazards present? No

V. Health and health practices

A. Common illness encountered for the last 6 months and the treatment applied.

Cough & colds

B. Whom do you consult for health-related problems?

Manghihilot

C. For problems other than health, whom do you consult?

Others, specify: Nurses at City Hospital

D. Immunization status of family

Complete Vaccine

E. Have you had adequate

1. Rest and sleep? Yes

2. Exercise? Yes

3. Relaxation activities? Yes

4. Stress management activities? Yes