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FAMILY HEALTH ASSESSMENT

FORM
Respondent:____________________________________________________________ Age:______
Stage:__________________________________________________________________ Sex:______
Relation to Head:_________________________________________________________(If not the Head of the Family)

I. Family Data:
A. Head of the Family:________________________________________ Age:______

B. Name of Spouse:__________________________________________ Age:______

C. Address:__________________________________________________ Contact No: ______________

D. Educational Attainment: _________________________________________________

i. Husband:________________________________ Occupation:_______________________
ii. Wife:____________________________________ Occupation:_______________________

E. Length of Residency: ______________________________

F. Ethnic Origin: ____________________________________

G. Family: Nuclear ☐ Extended ☐

H. Religion: ________________________

I. No. of Children: __________________

J. Members of the Household: ________

Name Relation to Head Age Sex Status Education Occupation

II. Socio-Economic Data

A. Source of Income
Occupation:
Husband:

☐ Employed
☐ Self- Employed
☐ Unemployed

Wife:

☐ Employed
☐ Self- Employed
☐ Unemployed

Joint Monthly Income

☐ Below 2,000.00 ☐ 3,000.00 – 5,000.00


☐ 5,000.00 – 8,000.00 ☐more than 8,000.00

B. Basic Expenditures

1. Food Daily
☐ Below 50.00 ☐ 50.00- 75.00
☐ 75.00 – 100.00 ☐more than 100.00
2. Clothing: number times of buying in a year
☐ Once ☐ Twice
☐ Thrice ☐more than Four Times

3. Housing
☐ Water ☐ Electricity
☐ Telephone

4. Schooling
☐ Public ☐ Private

5. Others: _________________________________________

C. Nutrition

1. Food Preference
☐ Fish ☐ Fruits/Vegetables
☐ Meat ☐ Mixed

2. Common Food
☐ Rice and Egg ☐ Rice and Sardines
☐ Rice and Noodles ☐Others: __________

D. Housing and Environment Condition

A. Home

1. Type of Housing
☐ Concrete ☐ Wood
☐ Mixed ☐ Makeshift
Others: _______________________

2. Ownership
☐ Owned ☐ Rented
☐ Rent - Free ☐Others

3. Number of Rooms for Sleeping: _________


4. Ventilation:
☐ Poor ☐ Good

5. Lighting and Facilities


☐ Electricity ☐ Kerosene
☐ Others

6. General Surroundings
☐ Clean ☐ Dirty

Sanitary Observations: _____________________________________________________

B. Source of Water Supply

☐ Artesian Well ☐ Deep Well


☐ NAWASA ☐ Others: _________________

C. Storage of Drinking Water

☐ Refrigerated ☐ Covered
☐ Uncovered

D. Kitchen
☐ Electric Stove ☐ Gas Stove
☐ Firewood/Charcoal

E. Drainage
☐ Open ☐ Blind
☐ None
☐Sanitary Observation: ____________________________

F. Containers Used
☐ Plastic ☐ Jars
☐ Bottles ☐Others: _______________

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G. Toilet Facilities

Sanitary:

☐ Flush ☐ Pit Privy


☐ Shared ☐Owned
☐ Others: ______________________

Unsanitary:

☐ “Ballot” System ☐ Others: ______________________

H. Waste Disposal
☐ Collection ☐ Burning
☐ Burying ☐Open Dumping
☐ Garbage Cans ☐ Others: _____________________

I. Food Storage
☐ Covered ☐ Uncovered
☐ Refrigerated

J. Presence of Animals
☐ Dogs ☐ Pigs
☐ Cats ☐Chickens/Roosters
☐ Others: __________________

K. Backyard Gardening
☐ Vegetables ☐ Herbal
☐ Fruit-Bearing ☐Others: __________________

L. Community Observation
A. Sanitary Condition: ______________________________________
B. House Overcrowding/Congestion ☐ Yes ☐ No
C. Presence of breeding sites of vectors ☐ Yes ☐ No
D. Health Facilities: ________________________________________

E. Recreational Facilities: ___________________________________

F. Distance of House to the Nearest Health Care Facility

M. Immunization Status of Children (Under 5)


☐ Complete ☐ Incomplete

What Vaccine was not given?

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