FAMILY HEALTH ASSESSMENT TOOL

City: Pasay City Barangay: 183

Family Name: Bojorque Address: Parkside Villas

I. FAMILY STRUCTURE
A. FAMILY STRUCTURE AND CHARACTERISTIC FACTORS
Family Member(s) Position Gender Age Birthday Civil
No Name (M/F) (mm/dd/year) Status
.
1 M.S.B 1st Child F 20 12-01-1999 Single
2 C.J.S.B 2nd Child F 19 12-18-2000 Single
3 R.R.S Mother F 41 9-17-1978 Single
4 L.D.B Father M 58 2-28-1963 Sigle

B. PATTERNS OF MIGRATION
Name of Member Place of Origin Reason for Dialect(s) Spoken
Migrating

C. TYPE OF FAMILY STRUCTURE

( ) Nuclear
( / ) Extended
( ) Others (specify):

D. DOMINANT HEAD OF THE FAMILY (In terms of decision-making)

( / ) Matrilocal
( ) Patrilocal
( ) Others (specify):

E. RESIDENCY (How long are they living the area?)

( / ) Permanent
( ) Transient

II. SOCIO-ECONOMIC AND CULTURAL

A. SOCIAL INDICATORS
1. Are you a member of any organization within the community?
( ) YES ( / )NO
If NO, because I did not join any.
Name of Organization:
Position:

2. Source of Information (news & current events)

( ) Radio ( ) Newspaper
( / ) Television ( ) Barangay meetings
( ) Neighbors ( ) Others (specify):

3. Transportation System
( ) Tricycle
( ) Pedicab
( / ) Jeepney
( ) Others (specify):

EDUCATIONAL ATTAINMENT/RELIGION/OCCUPATION
Name of Highest Religion Occupation Specify if Place of Work
Family Educational Employed, Self
Member(s) Attainment Employed,
Unemployed or
Underemployed
M.S.B 3rd yr Roman Student
Nursing Catholic
Student
C.J.S.B 2nd yr Roman Student
Tourism and Catholic
Managemen
t Student
R.R.S Graduated Roman House Wife Unemployed
Computer Catholic
Secretariat
L.D.B 3rd yr High Roman Tricycle Self Employed Bicol
School Catholic Driver

Combined Family Monthly Income

(members ages from 15 - 64 years old)
( ) less than 1,000.00 ( / ) 10,001 - 15,000
( ) 1,000.00 - 5,000.00 ( ) 15,001 - 20,000
( ) 5,001.00 - 10,000 ( ) 20,001 - 25,000

Allocation of the Family Income

(Put a check mark if the item is most prioritized and a cross mark if least
prioritized)
( / ) Food and Drinks
( / ) Education
( / ) Health
( / ) Monthly bills
( ) Games and Recreation
( ) Others (specify):

III. HOME & ENVIRONMENT

1. Housing Conditions
1. a. Ownership
( / ) Owned ( ) Rented - Free
( ) Rented ( ) Shared
( ) Others (specify):

1. b. Housing Material
( ) Wood
( / ) Concrete
( ) Mixed
( ) Makeshift

1. c. Lighting facilities
( / ) Electric
( ) Kerosene
( ) Candle
( ) Others (specify):

1. d. Ventilation
( / ) Adequate
( ) Inadequate

1. e. Housing Congestion
( ) Congested
( / ) Not Congested

1. f. Cooking Facility
( / ) Electric Stove
( ) LPG
( ) Kerosene
( ) Firewood
( ) Charcoal

1. g. Food Storage
( / ) Refrigerated
( ) Cabinet
( ) Others (specify):

1. h. Kind of Household Pet

( / ) Dog ( ) Bird
( ) Cat ( ) Fish
( ) Others (specify):

1. i. Immunization of Dogs
( / ) With Immunization
( ) Without Immunization

ENVIRONMENTAL INDICATORS
1. Physical Characteristics of the Community
1. a. General Sanitary Condition
( / ) Sanitary ( ) Unsanitary
 1. b. Drainage facility
( ) Open Drainage
( / ) Blind/Closed Drainage
( ) None

1. c. Presence of Vectors
( / ) Mosquitoes
( ) Rats
( / ) Cockroaches
( / ) Flies
( ) Others (specify):

Does the family address this vector problem? YES

If yes, by spraying insecticides when everyone is off to bed.
If no, why?

2. Water Supply
a. Source of Water Supply for General Use
( / ) MWSS (Maynilad)
( ) Deep Well
( ) Purified
( ) Others (specify):

b. Source of Water Supply for Drinking

( ) MWSS (Maynilad)
( ) Deep Well
( / ) Purified
( ) Others (specify):

If Deep Well:
Distance from the septic tank:
If boiled, how long?
If not boiled, why?

c. Storage of Drinking Water

( / ) Refrigerated
( / ) Covered
( ) Uncovered

3. Waste disposal
a. Garbage Disposal System
( / ) DPS Collection
( ) Burning
( ) Open Dumping
( ) Burying/Composting
( ) Throw in the river or sewer
( ) Others (specify):
 b. Receptacle Used for Garbage Disposal
( / ) With Cover
( ) Without Cover
( / ) Plastic Bag
( ) No Receptacle
( ) Others (specify):

c. Waste and Excreta Disposal

( / ) Flush (with water closet and septic tank)
( ) Water-sealed/Pour flush (with septic tank)
( ) Pit privy
( ) Wrap and Throw (flying saucer)
( ) Public Comfort Room
( ) Shared
( ) Others (specify):

IV. VALUES & PRACTICES

A. PRIMARY SOURCE OF MEDICAL CARE
( ) Health Care ( / ) Hospital ( ) Private ( ) Others
Physician (specify):

1. What is the distance of the client’s house to the health care?

( ) 1km (/ ) >1km ( ) <1km ( ) Others (specify):
2. How does the client go to the Barangay Health Center?
( /) Walking ( ) Riding
3. How often does the client receive visits from the barangay health
workers?
(/ ) none ( ) every week ( ) every 2 weeks ( ) every month ( ) Others
(specify):
4. From who does the client obtain information about HEALTH?

B. MEMBERS OF THE FAMILY WHO DRINK, SMOKE AND USES

RECREATIONAL DRUGS
Name Cigarette Smoking Alcohol Drinking Types and
No. Of No. Of No. Of How Often Amount of
sticks/day packs/day bottles Drugs
uses/day
M.S.B 1 Occasionally
L.D.B 5 1 More than 2 alcoholic

V. MEMBERS’ HEALTH STATUS

A. FAMILY PLANNING
1. Does the client practice family planning?
( / ) YES, Why?
( ) NO, Why?
2. Method of Family Planning Used
( ) Artificial ( / ) Natural ( ) Permanent/Surgical

3. Kinds of Contraception Used

( ) Pills ( ) IUD ( / ) Condom ( ) Calendar ( ) Others
(specify):

B. MATERNAL CARE
1. No. Of children born 2
2. Who handled the delivery? ( )Physician ( )Hilot
( / )Midwife ( )Nurse
( ) Others (specify):
3. Place of delivery? ( ) Hospital ( )Home
( )Lying-in ( )Others
4. No. of times Pregnant 2
5. No. Of deceased infants (0-12mos.) none
6. CAuse of death of the infant none
7. No. Of prenatal check ups during Can’t Remember
pregnancy
8. Did the mother receive any tetanus ( / )Yes
toxoid vaccines during pregnancy? ( )No, Why?
9. Did the mother recieve any iron and ( / )Yes
folic acid supplements during ( )No, why?
pregnancy?
10. Any complications during labor none
and delivery?
11. Any incidence of maternal deaths ( )Yes, Number:
within the family? ( / )No

C. CHILD CASE
1. Immunization Status
( / ) Complete ( ) On-going
( ) Incomplete ( ) No Immunization

2. Child Nutrition
Milk Feeding
( ) Breast ( ) Formula ( / ) Mixed

D. PRESENT ILLNESS
Member(s) Disease/Illness Illness Illness
of the Suffered
Family
Medically Attended Diagnosed Symptomatic
Attended by the
Family
 E. PAST ILLNESS (past 5 years)
Diseases Illness Illness
Diagnosed Symptomati Medically Attended Attended
c Attended by the by quack
Family Doctor

F. INCIDENCE OF MORTALITY (fort he past 5 years)

Name of Member(s) Cause of Death

G. INCIDENCE OF HOSPITAL ADMISSION (for the past 5 years)

Name of Member(s) Medical Diagnosis

POLITICAL/LEADERSHIP PATTERNS

1. Who is the leader in your barangay?

________________________________________________________
2. Is he an effective leader?
________________________________________________________
3. Does your community respect him as a leader?
________________________________________________________
4. What are the issues or problems in your barangay?
________________________________________________________
5. How is it resolved?
________________________________________________________
6. Do you think there are better ways to reslove the problem?
________________________________________________________