FAMILY SERVICE AND PROGRESS RECORD

HEAD OF THE FAMILY Rodalyn quilang FAMILY NUMBER: 09388267490

ADDRESS: san mariano isabela cataging sitio matoya

________________________________________________________________________________________

I. Assessment of the Family, Home and Environmental Conditions:

A. Members of the Household

HIGHEST Religion REMA

RELATIO S EDUC RS/
MARITAL
FAMILY MEMBER N TO THE E BIRTHDATE COMPLET OCCUPATION DATE
STATUS
HEAD X ED ENTER
ED
N Name Month Year Type of Place
o work
1 Rodalyn quilang Head M August 1978 Married - Catholic farmer isabela
28
2 Oliver quilang Wife F Jul12 1983 Married - Catholic House isabela
wife
3 Bernadeth quilang Daughter F Novem 2001 Single college Catholic - -
ber 20
4 Mary anne Daughter F Decem 2002 Single Grade 12 Catholic - -
ber 28
5 Oliver quilang jr Son M Februa 2005 Single Grade 10 Catholic - -
ry 10
6 olivia Daughter F June 27 2008 Single Grade 7 Catholic - -
7 Kim Caitlyn quilang Daughter F June 6 2010 Single Grade 5 Catholic - -
8
9
10

B. Home and Environment

Date Assessed: ____________________________________________________
1. Home
a. Ownership: ( ) Owner) ( ) Rented ( /) Rent-Free
b. Construction Materials used: ( ) Light ( /) Mixed ( ) Strong
c. Number of rooms for sleeping: 2
d. Lighting facilities ( /) Electricity ( ) Kerosene ( ) Others Specify
e. General sanitary condition: Maintained good sanitary condition daily
f. Drinking water supply
Source: ( / ) Private ( ) Public Potability: Efficiently drinkable
Distance from house: walking distance (10 meters)
Storage: ( ) None (Direct from faucet or pipe)
( /) Large covered container with faucet
( ) Large uncovered container without faucet
( ) Others, Specify ____________________________________________________
2. Kitchen
Cooking facility: ( ) Electric stove ( ) Gas Stove ( / ) Firewood/charcoal
 Sanitary condition: Good sanitary condition
Drainage Facility: ( / ) Open drainage ( ) Blind drainage ( ) none
3. Waste Disposal
a. Refuse and garbage
Container: ( / ) Covered ( ) Open ( ) None
b. Method of Disposal: ( ) Public garbage collection ( /) Burning ( ) Compose pit
4. Environmental Factors
a. Geographic Features: ( / ) Land ( /) bodies of water (/ ) Mountains
b. ( ) Flora ( / ) Fauna
C. Economic Indices
1. Source of income: Farm sales
2. Average family income: 20,000
3. Monthly family expenditure: 10,000 to 15,000
4. Land and house ownership
a. Land ownership: Rent-free
b. House ownership: Rent-free
5. House ventilation: 3 Electric Fans
D. Health Assessment
Distance of Health Center: Walking distance/ 1 ride away (500 meters)
Use of Herbal Medicine/ Other practices:
Vaccination: ( /) All Family member vaccinated ( ) None ( ) few of family members please specify:

Diagnosis Yes No When was it Medications (Name of drug and Dosage)

diagnose?
Hypertension l 2019 Lozartan

Diabetes l

Cardiac Problems l

Diarrhea l 2018-Present -

Urinary Tract L 2018 -

Infection panganay

Others, please
specify:

1. Non-Modifiable Risk Factor

2. Modifiable Risk Factors

Type of Food Eaten Frequency

Vegetable everyday
Fruits Sometimes
Fish 2x/week
Meat 6x/week
Processed Food none
Salty Foods (e.g: ham, nuts, salted egg, junk foods) 1x/week
Sweet foods (e.g candy, sweetened pineapple, 2x/week
teas)
Oily Foods (e.g. Bacon, liempo,) 1x/week

3. Smoker/s, alcohol drinker/drug user

a. Prohibited Drug User: ( ) Yes ( / ) No
b. Smoker/s: ( ) Yes ( / ) No If not: expose to secondary smoking ( ) Yes ( ) No
c. Alcohol drinker/s: ( / ) Yes ( ) No

NAME ALCOHOL Duration FREQUENCY? SMOKER Duration NO. OF

DRINKER STICK
father Yes 15 years 2x/week - - -

4. Weight
A. Number of Overweight in the Family: none
B. Number of underweight in the Family: 1x- bunso