FAMILY HEALTH ASSESSMENT FORM

Respondents: Age:

Stage: Sex:

Relationship to Head: (If not the Head of the Family)

I. Family Data

A. Head of the family Age

B. Name of Spouse Age

C. Address Tel No.

D. Educational Attainment

i. Husband
ii. Wife

E. Length of Residency
F. Ethnic Origin
G. Family
Nuclear ( ) Extended ( )
H. Religion
I. No. of Children
J. Members of the Household

Name Relation to Head Age Sex Status Education Occupation

II. Socio-economic Data

A. Source of Income
Occupation:
Husband:
Employed ( ) Unemployed ( )
Self-employed ( )

Wife:
Employed ( ) Unemployed ( )
Self-employed ( )

Joint Monthly Income

Below Php 2,000 ( ) Php 3,000 - Php 5,000 ( )

Php 5,001 - Php 8,000 ( ) more than Php 8,000 ( )

B. Basic Expenditures
1. Food daily

below Php 50 ( ) Php 50 – 75 ( )

more than Php 75 ( )

2. Clothing: number of times of buying in a year

once ( ) twice ( )
thrice ( ) more than four timea ( )

3. Housing
water ( ) electricity ( )
telephone ( )

4. Schooling
public ( ) private ( )

5. Others

C. Nutrition
1. Food preference
fish ( ) fruit/vegetables ( )
meat ( ) mixed ( )

2. Common fare
 rice and egg ( ) rice and sardines ( )
rice and noodles ( ) Others

III. Housing and Environmental Condition

A. Home
1. Type of Housing
concrete ( ) wood ( )
mixed ( ) makeshift ( )
others:

2. Ownership
owned ( ) rented ( )
rent-free ( ) others:

3. Number of rooms for sleeping:

4. Ventilation:
poor ( ) good ( )

5. Lighting facilities:
electricity ( ) kerosene ( )
others:

6. General surroundings:
clean ( ) dirty ( )
sanitary observations:

B. Source of Water Supply

artesian well ( ) deep well ( )
NAWASA ( ) others:

C. Storage of drinking water

refrigerated ( ) covered ( )
uncovered ( )
D. Kitchen:
electric stove ( ) gas stove ( )
firewood/charcoal ( )

Drainage

open ( ) blind

none ( )

Sanitary Observations:

E. Containers Used
plastic ( ) jars ( )
bottles ( ) others

F. Toilet Facilities
Sanitary:
flush ( ) pit privy ( )
others
shared ( )

Unsanitary:
“ballot” system ( ) others

G. Waste Disposal
Collection ( ) burning ( )
Burying ( ) open dumping ( )
Garbage cans ( ) others

H. Food Storage
Covered ( ) uncovered ( )
Refrigerated ( )

I. Presence of Animals
Dogs ( ) rats ( )
Pigs ( ) others ( )
 J. Backyard Gardening
Vegetables ( ) herbal ( )
Fruit-bearing ( ) others

K. Community Observation
a. Sanitary condition:

b. House overcrowding/congestion: Yes ( ) No ( )

c. Presence of breeding sites of vectors: Yes ( ) No ( )
If yes. specify:

d. Health facilities:

e. Recreational facility:

f. Distance of house of the nearest health care facility:

IV. Health Needs and Problems

Health Nursing Care Evidence/ Identification

Needs and Problems Date and
Problems Intervention

In case of Home Visit:

FAMILY NURSING CARE PLAN

 Nursing Objective of Planning and Evaluation of
Needs and Nursing Care Intervention Outcomes
Problems

FAMILY PROGRESS REPORTS

Date Health Needs Observations, Signed
and Actions Taken,
Problems Progress,
Evaluation

FAMILY COPING CHECKLIST

Coping Areas 1 2 3 4 5 Explanation

1. Physical independence

2. Therapeutic
Independence
3. Knowledge of Health
Condition
4. Principles of Personal
 Hygiene
5. Attitude Toward Health
Care
6. Emotional
Competencies
7. Family Living Patterns
and Lifestyle
8. Attitude Toward
Environment
9. Available of Community
Health resources
10. Socio-economic
Condition
11. Geographic and
Environment Conditions
12. Family Structure
and Support System

1-Poor, 2-fair, 3-Average, 4-Satisfactory and 5-Very Satisfaction

Interviewed by:
Date: ; Time: