Central Philippine Adventist College

SCHOOL OF NURSING
ACSCU-AAI Level II
AAA Accredited
Tel. No. (034) 704-1004 Loc.116/117; Email: nursing@cpac.edu.ph; Website: www.cpac.edu.ph;

Family Health Assessment Form

Head of the Family Name: _____________________________________________________________

House No.___________________________________Street:_________________________________
Barangay: ___________________________________ Municipality/ City: _______________________
Source(s) of Information: _____________________________________________________________
Data Gathered by___________________________________________Date:____________________

HOUSEHOLD MEMBERS
NAME AGE/S RELATIONSHIP TO HEAD Marital Highest Educ. Occupation
ex Status
OF HOUSEHOLD Attainment
(Wife, sister, son etc.)

Note: Insert Genogram, family tree (indicating health problems of individual members) & ecomap (relationship or
utilization of family to the services to the different agencies within the community) here.

Family Genogram:

Ecomap:

Family Structure and Characteristics (narrative form)

Family members living outside the Household
Name, age, relationship to head of household, location of family members, frequency and duration of contact &
means of communication

Family mobility
Length of time at current address, frequency of geographic moves

Family Dynamics
Emotional bonding of family members
Distribution of authority & power
 Central Philippine Adventist College
SCHOOL OF NURSING
ACSCU-AAI Level II
AAA Accredited
Tel. No. (034) 704-1004 Loc.116/117; Email: nursing@cpac.edu.ph; Website: www.cpac.edu.ph;

Degree of individual autonomy

How members communicate
How decisions are made
How problems are solved
How conflict is handled
Division of labor
Socio-Economic & Cultural Characteristics (narrative from)
Family Social Integration Language(s)
or dialect(s) spoken
Literacy (ability to write & read in language (s)
Degree of social network with friends, neighbors & others relatives
Network with religious organizations
Economic
Educational experiences
Work history
Adequacy of financial resources
Leisure time interests
Include Monthly family budget breakdown (income and expenses)
Sources of Income Monthly Income in Pesos Family Expenses Monthly Expenses
(Approximate) (Approximate) (Approximate in pesos)

Food
House rental if any
Water
Electricity
School fees
Miscellaneous
Total: Total:
Cultural influences: values, attitudes, & beliefs about:
Spirituality
Rituals (holidays & celebrations)
Dietary habits
Health
Folk diseases
Traditional healers

Home Environment
Housing
Adequacy of size of Living space
Sleeping arrangement (Insert Floor Plan )
Structural materials & safety (wood, concrete or semi-concrete)
Kitchen, Food preparation & storage
Water Supply
Toilet facility
Garbage disposal
Drainage System
Pest & vermin control
Kind of Neighborhood
Location (e.g. urban, rural, subdivision, slum area)
Type (e.g. residential, semi-commercial)
Safety- traffic patterns, lighting & security
Population density (crowding)
Sources of population (air, water, soil and noise) if any
Family social, health behavior & availability of health facilities
Activities of daily living (how family spends a typical day)
Self-care (health promotion & disease prevention)
 Central Philippine Adventist College
SCHOOL OF NURSING
ACSCU-AAI Level II
AAA Accredited
Tel. No. (034) 704-1004 Loc.116/117; Email: nursing@cpac.edu.ph; Website: www.cpac.edu.ph;

Risk behavior if any

Health Care Resources (health workers & health agencies)
Use of home remedies
Communication & Transportation Available
Health Status of each Family Member

1. Current Illness
Family Member Illness/Disease MedTreatment Received

2. Nutritional Assessment, Habits & Practices

A. Dietary History
5 days diet recall
DAY Breakfast Lunch Dinner
1st day
2nd day
3rd day
4th day
5th day
3. Eating Habit practices
4. Health habits, values & practices
5. Activities & Exercise
6. Adequacy of Rest

PHYSICAL ASESSMENT OF EACH FAMILY MEMBER Date Performed:__________________

(Focused assessment, highlight abnormal findings if any)
Family Member 1. 2. 3. 4.

Vital Signs (TPR &

BP)
General Appearance

Skin & nails

Head & Hair
Mouth
Eyes & Vision
Ears & Hearing
Nose & sinuses
Neck, Lymph nodes
& Thyroid gland

Lungs
Heart ( HR) rhythm

Abdomen
Musculoskeletal
Neurological
Anthropometric
measurements:
weight
 Central Philippine Adventist College
SCHOOL OF NURSING
ACSCU-AAI Level II
AAA Accredited
Tel. No. (034) 704-1004 Loc.116/117; Email: nursing@cpac.edu.ph; Website: www.cpac.edu.ph;

Height
BMI