Family Name: Baysie

Family Members Data

Family Age Sex Civil Position Relationship Educational Occupation
Members Status in the to the Family Attainment
Family Head
Laylanie 29 F Single Elementary
Benjamine 37 M Single Elementary

A. Family Characteristics
Type of Family structure
Extended
Nuclear
Matriarchal
Patriarchal
Dominant Family Members:

B. General Family Relationship/Dynamics

CRITERIA CRITERIA ADDITIONAL
INFORMATION
(-)
Observable conflicts between
family members
(-)
Characteristics of
communication
Interaction patterns among (+)
members

C. Family Dietary Habits

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

Breakfast: coffee, tinapa, noodles

Lunch: noodles, egg, rice
Supper: same with lunch

D. Type of House?

Wood mixed
Concrete makeshift

E. Is the living space adequate?

yes no
F. What are the appliances owned by the family?

G. Garbage disposal

collected burning
Waste segregation burying
feeding to animals throw to the river
Open dumping others, specify; ____

H. Type of waste disposal

flush water-sealed
wrap and throw pity privy
others, specify; public

I. Type of drainage system

Open close

J. Sources of water storage

owned shared
bought others, specify; ____

K. Drinking water storage

Refrigerator covered
uncovered others, specify; ____

L. Container used
Plastic pitchers jars, clay part
bottles others, specify; ____

M. Food storage/cooking

covered uncovered
Refrigerator cabinet
Refrigerator covered
stove others, specify; ____

N. Common household pests found at home

 daga, lamok, ipis

O. Are there breeding site of insect, rodents, ect. present?

yes no

P. Pets/animal kept in the yard/home

yes no

Q. Are there accident hazards present?

yes no
Health and Health Practices

A. Common illnesses countered for the last 6 months and the treatment applied.
 Cough and colds

B. Whom do you consult for health related problems?

Manghihilot albularyo
Midwife nurse
Doctor Health Center
Brgy. Health workers others, specify; ____

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

family members relatives

friends Brgy. official
priest others, specify; ____

D. Immunization status of family members

all children
some of them
not yet vaccinated

E. Have you have adequate

Rest and sleep: yes no


Exercise: yes no
Relaxation activities: yes no

D.Present illness

Disease/illness suffered W/ medical assistance w/o medical assistance

Colds/cough neosep

E.Past illness
Disease/illness suffered W/ medical assistance w/o medical assistance
Colds/cough neosep
fever biogesic