You are on page 1of 4

FAMILY CARE STUDY

Introduction

Spot Map

Family Profile

Health History (All Members)

Present Health Status (All Members)

Physical Assessment (All Members)

Home and Environment

Family Health Care Plan (Include Referral)

Nursing Care Plan (For Morbid Cases)

Actual Implementation

Evaluation

FAMILY PROFILE

Head of the Family: ____________________________________________________


Address: _____________________________________________________________

Members of the Family

Name Gender Birth date Age Highest Education Completed Occupation Income
Immunization

Name of Child Fully Immunized Complete Immunized Incomplete Wala

Family Planning

Methods
Natural Method Permanent Method Temporary Method Wala

Heredo-Familial Disease

( ) Hypertension
( ) Cancer
( ) Asthma
( ) Diabetes
( ) Arthritis
( ) Mental Retardation
PAST FAMILY HISTORY

Previous illness/ surgery

Type of previous illness/surgery Date Type of previous illness/surgery Date

Has received blood in the past:


( ) Yes
( ) No
If yes, indicate Date_______________
Reactions ( ) Yes ( )
No

Allergies

Name of Member Medication Name Dose/Frequency Time of Last Dose


HOME AND ENVIRONMENT

HOME
b. General sanitary condition: ____________________________
a. Ownership: ( ) Owned ( ) Rented ( ) Rent-free
b. Construction materials used: ( ) Light ( ) Mixed ( ) Strong
c. Number of rooms used for sleeping: _____________________
d. Lighting Facilities: ( ) Electricity ( ) Kerosene ( )
Others______________
e. General sanitary condition: ________________________________________

WATER SUPPLY
a. Drinking water
Source: ( ) Private ( ) Public
Distance from the house: ______________________________________
Storage: ( ) None, direct from the faucet
( ) Container with cover
( ) Container without cover
( ) Others ______________________________________

KITCHEN
a. Cooking facility: ( ) Electric stove ( ) Gas Stove ( )
Firewood/Charcoal

DRAINAGE SYSTEM
a. Drainage facility: ( ) None ( ) Open drainage ( ) Blind/close
drainage

WASTE DISPOSAL
a. Garbage disposal
1. Container: ( ) Covered ( ) Open ( ) None
2. Method of disposal: ( ) Opening dumping ( ) Open burning
( ) Compost pit
b. Toilet
1. Type
( ) Pit privy ( ) Pail system
( ) Flush type ( ) Antipolo System
( ) Water-sealed ( ) none
c. Distance: ______________________________________________________
d. General sanitary condition: ________________________________________

DOMESTIC ANIMALS:

Kind Number Place kept


COMMUNITY IN GENERAL
a. Housing congestion: _________________________________________________
b. Recreational facilities: ________________________________________________
c. Type of Health Care Facility: ___________________________________________
d. Distance of house from the nearest Health Care Facility:
_____________________
e. General Sanitary Condition: ____________________________________________