Mindanao State University

COLLEGE OF HEALTH SCIENCE

FAMILY HEALTH SURVEY FORM

I. Family Structure, Characteristics, and Dynamics.

A. Type of family
Nuclear Extended Others (specify)
B. Family Structure
Patriarchal Matriarchal
C. Family Size
Small (1-4) Medium (5-6) Large (7 up)
D. Dominant family member in terms of decision-making, especially in matters of health care
Father Mother Other (specify)
E. Demographics

Family Members Position in the family Age Sex Civil Status

II. Socioeconomic and Cultural Characteristic

A. Employment Status

Family Member Employed Unemployed Self- Type of

employed Occupation

B. Monthly Income per household

500-999 1000-1999 2000-2999

3000-3999 4000-4999 5000-above
C. Monthly Expense per household
500-999 1000-1999 2000-2999
3000-3999 4000-4999 5000-above
D. Adequacy to meet basic needs (food, shelter, clothing)
More than adequate Adequate Not adequate
E. Ethnicity:
F. Religious affiliation:
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COLLEGE OF HEALTH SCIENCE

G. Relationship of the family in community activities

1. Attendance in social activities (weeding, funerals, etc) Yes No

2. Participation in political activities Yes No

3. Participation in healthcare activities Yes No

H. Educational Attainment (No formal education, Elementary level, Elementary Graduate,

High School level, High School graduate, College level, College graduate)

Family Member Educational Attainment

III. Home and Environment

A. Residency
Less than 6 months More than 6 months
B. Home ownership
Owned Rented Rent-Free
C. Land ownership
Owned Rented Rent-Free
D. Types of House
Concrete Wood Concrete/Wood Makeshift
E. Types of housing structure
Single-attached Single-detached Two-Storey
F. Electricity availability
With electricity Without electricity
G. Means of Cooking
Electricity stove Wood/charcoal Kerosene
LPG Others (specify)
H. Food Storage
With refrigerator Without refrigerator Others (specify)
I. Water Source
Deep well Communal Others (specify)
Rain water Lake/River
J. Storage of drinking water
With cover Without cover Others (specify)
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COLLEGE OF HEALTH SCIENCE

K. Garbage disposal
Compost pit Burning Collected Open dumping
L. Type of toilet
Pit latrine Pail system Septic tank/flush
M. Drainage system
Open drainage Closed system
IV. Health Care
A. Person to consult when family member are sick
Doctor Nurse/Midwife Faith Healer Self-medication
B. Type of Birth Attendants
Doctor Midwife Trained Hilot
C. Place of Delivery
Private Hospital District Hospital Health Center House
D. Infant feeding Practices
Breast Feeding Bottle Feeding Mixed Feeding
E. Use of Herbal Medicines
Lagundi Acapulo Sambung
Bawang Luya Bayabas
Tsaang-Gubat Ampalaya ___ Others (specify)
F. Heigh and Weight

Name of Children Age Heigh Weight BMI Remarks

t

G. Immunization of the Children

Name of Children Age in Months Incomplete Complete Fully Immunized

V. Responsible Parenthood
A. Family Planning
Practicing FP Not Practicing FP
B. Method used in Family Planning
IUD Pills Condoms Ligation
Rhythm Withdrawal Other (specify)

VI. Health and Medical Records

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COLLEGE OF HEALTH SCIENCE

A. Major Illnesses (Past and Present)

Hypertension DM Cardiac Disease PTB Pre-eclampsia
Anemia Rheumatism Anemia Others
B. Common Minor Illness
Fever Colds Headache
Toothache Cough Others (specify)
C. Cause of Death
Hypertension DM Cardiac Disease PTB
Cancer CVA Pre-eclampsia Liver Disease
Accident others (specify)

VII. Issues or situations in the family

A. Health Problems/Issues/concerns of the family or family member

B. Causes and Possible Solutions

C. Other Needs of the Family

D. Solution to the Needs of the Family

Name of family: Date:

FIRST LEVEL OF ASSESSMENT

I- Presence of Health Threats

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COLLEGE OF HEALTH SCIENCE

(Conditions that is conductive to disease and accident that may result in failure to maintain
wellness)
A. Presence or family history of:
Diabetes Mellitus
Cancer; specify:
Hypertension
Cardiovascular Disease; specify:
Other, specify:
B. Presence of family members with communicable disease
c YES NO
specify communicable disease:
C. Family size beyond what family resources can adequately provide
YES NO
No. of family members: Estimated total family income: ____
D. Presence of accident hazards
Broken chairs
Pointed/Sharp objects
Poisons and medicines improperly kept
Fire Hazards
Fall Hazards
Residence near river/lake
Others, specify:
E. Faulty/unhealthy nutritional or eating habits or feeding techniques or practices
Inadequate food intake both in quality and quantity
Excessive intake of certain nutrients, (specify family member)
Faulty eating habits e.g. eating late, skipping meal and others
Ineffective breast feeding/faulty feeding techniques
F. Stress provoking factors
Strained marital relationship
Strained parent-sibling relationship
Interpersonal conflicts between family members
Care giver burden

G. Poor home/environment condition or sanitation

Inadequate living space
Lack of food storage facilities
Polluted water supply
Presence of breeding or resting sights of vectors of diseases
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COLLEGE OF HEALTH SCIENCE

Improper garbage disposal

Poor lighting
Poor ventilation
Noise pollution
Air pollution
H. Unsanitary Food handling and preparation
YES NO
I. Unhealthy lifestyle and personal habits/practices
Alcohol drinking
Cigarette/tobacco smoking
Walking barefoot
Eating raw meat or fish
Poor personal hygiene
Substance abuse
Sexual promiscuity
Engaging in dangerous sports
Inadequate rest or sleep
Lack of inadequate exercise/physical activity
Lack of relaxation activities
Non-use of self-protection measures (mosquito nets)
Other, specify
J. Inherent personal characteristics (e.g. short temper, poor impulse, control etc.)
YES NO family members:
K. Inappropriate role assumption (e.g. child assuming mother’s roe/father not assuming his
role)
YES NO family members:
L. Lack of immunization/inadequate immunization status of children
YES NO family members:
M. Presence of family disunity
YES NO family members:
Other health threats:

II- PRESENCE OF HEALTH DEFICITS

(Instance of failure in health maintenance)
A. Presence of Illness (diagnosed or not) YES NO
Illness Members of the family
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COLLEGE OF HEALTH SCIENCE

B. Failure to thrive/develop according to normal process

YES NO
Type of failure Member of the family

C. Presence of disability (e.g. blindness, amputation, lameness from polio)

YES NO
Type of failure Member of the family

III- PRESENCE OF STRESS POINTS/FORESEEABLE CRISIS SITUATIONS

(Anticipated periods of unusual demand on the individual or family in terms of
adjustment/family resources)
Marriage
Pregnancy, labor, puerperium
Parenthood
Additional member (e.g. newborn, lodger)
Entrance at school
Adolescent
Divorce/separation
Menopause
Loss of job
Hospitalization of a family
Death of family member
Resettlement in new community

AUBREY DYNISE C. TORRALBA

STUDENT NURSE