FIRST LEVEL OF ASSESSMENT I. Presence of Health threats, Health deficits, Foreseeable crisis/ stress points of the family.

A. Health Threats (Color the applicable vertical scrolls) Family history of hereditary diseases Specify disease/s: Hypertension Family size beyond family resources Threats of cross-infection from a communicable disease Specify disease/s: cough and colds, fever Inappropriate immunization status especially of children: Poor environmental situation Inadequate living space Inadequate personal belongings/utensils Lack of food storage Polluted water supply Presence of breeding places of insects and rodents Improper refuse disposal Improper drainage system Poor ventilation and lightning Noise pollution Unsanitary food handling and preparation Others, please specify: ____________________________

Inherent personality characteristics Short temper Others, please specify: _______________________________ Inappropriate role consumption Child assuming mothers role Others, please specify: _______________________________ Accident hazards Broken stairs Pointed sharp objects Poison and medicines improperly kept Fire hazards Fall hazards Others, please specify: Unprotected stairs Nutritional Inadequate food intake both in quality and quantity Excessive intake of certain nutrients Faulty eating habits Others, please specify: _________________________ Stress provoking factors Strained marital relationship Immature parents Interpersonal conflicts between family members Others, please specify: _________________________

Personal habits/practices Excessive smoking Walking barefooted Eating raw fish and meat Poor personal hygiene Self-medicated Others, please specify: _________________________ Health history that may precipitate the occurrence of a health problem Specify: Hypertension Family disunity Self-oriented behaviour Unresolved conflicts Intolerable disagreements Others, please specify: _________________________ B. Health Deficits (Enumerable and discuss briefly) Malnutrition The children shows signs and symptoms of malnutrition (underweight, poor skin integrity) Diarrhea one their children shows impending characteristics of diarrhea that predisposes him in dehydration that may alter the normal functioning of his body. Some of the manifestation are frequent defecation in just one day and watery stool. C. Stress points/foreseeable crisis situations

SECOND LEVEL OF ASSESSMENT I. Inability to recognize the presence of a problem due to: Ignorance of facts Fear of consequences of diagnosis of problem Social (Stigma, loss of respect of peer/significant others) Economic (Cost) Physical/Psychological Attitude/Philosophy in life

II. Inability to make decisions with respect to taking appropriate health actions due to: (Color applicable horizontal boxes) Failure to comprehend the nature, magnitude or scope of the problem Low salience of the problem Feeling of confusion and resignation brought about by failure to breakdown problems into manageable units of attack Lack of knowledge/insight as to alternative course of action open to them Inability to decide which action to take among the list of alternatives Conflicting opinion among members regarding action to take Ignorance of community resources for health care Fear of consequences of action Social

Economic Physical/Psychological Negative attitude toward the health problem Lack of trust/confidence in health personnel/agency Misconception of erroneous information about proposed course/s of action Inability of appropriate resources of care Pregnancy, labor, puerperium Parenthood Additional member of the family Abortion Entrance at school Adolescence Loss of job Death of a member Illegitimacy Resettlement in a new community Others, please specify: ______________________________ Physical (location) Cost III. Inability to provide nursing care to the sick, disabled, or dependent member of the family due to: ( Color the applicable horizontal scrolls) Ignorance of the facts about the disease/health condition

(Nature, severity, complications, prognosis, and management) Ignorance of the nature and extent of the nursing care needed Lack of necessary facilities (equipment and supplies) for care Lack of knowledge and skill in carrying out the necessary treatment/procedure/care Inadequate resources for care Responsible family member Financial Physical resources (e.g. isolation room) Failure to see benefits (especially long term ones) of investments in home environment improvement Present of physical/psychological conflicts Identify crisis/psychological conflicts Jealousy/rivalry Guilt feelings Others, please specify: _______________________________ Ignorance of preventive measures Attitude/philosophy on life Family disunity Self-oriented behaviour of members Intolerable disagreements Lack of support to members in crisis Others, please specify: _______________________________

IV. Inability to utilize community resources for health due to: ( Put Color Green to the applicable horizontal scrolls) Ignorance of lack of awareness of community resources for health care Failure to perceive benefits of health care/services Lack of trust/confidence in health agency/personnel Previous unpleasant experience with health worker Fear of consequences of action Physical/psychological Financial Social Unavailability of required care/services Inaccessibility of required care/services Cost Physical Inadequate family services Manpower Financial Feelings of alienation/lack of support form from the community Attitude/philosophy in life: