MISSION

“MABINI COLLEGES provides quality instruction,

MABINI COLLEGES INCORPORATED research and extension service programs at all

VISION Governor Panotes Avenue, educational levels as its monumental contribution to

national and global growth and development.
“MABINI COLLEGES shall cultivate a CULTURE of Daet, Camarines Norte Specifically, it transforms students into:
EXCELLENCE in education.” 1. God – fearing
Tel. no. (054) 721-1281 local 109 2. Nation – loving
3. Law abiding
Email: mabinicollege@hotmail.com 4. Earth caring
5. Productive, and
6. Locally and Globally competitive
persons

FAMILY HEALTH ASSESSMENT

Key Informant: Contact Number:

Primary Health Center:
Address:
Interviewed by: Bianca Ysabelle M. Regala Date of interview: March 27, 2021
(Name of Student)

1. IDENTIFICATION INFORMATION
Head of Family:

Occupation: Police Officer Monthly Income: 29, 668

Address: BAGASBAS, DAET, CN

Type of Family: Nuclear Joint/Extended Others: ____________

Religion:  Roman Catholic Muslim Christian Hindu/Mormons

Jehovah’s Witness Iglesia ni Cristo Dating Daan
Any other Pls. Specify: ___________________

Length of Residency: 6 rs

Ethnicity: BICOLANO

2. HOUSING CONDITION
I. Type of House: Completed  Partially Completed Independent

Material: Tiled Sheeted Hollow blocks/concrete

Mixed Anahaw Sawali

Ownership: Owned Rented Others: _________________

a. Room Number for sleeping: 2 ROOMS

b. Kitchen: Separate Part of the house part of the house w/ dirty kitchen

c. Fuel Used:  LPG Kerosene Firewood Electricity

d. Ventilation: Number of windows: Good (/) Poor ( )

e. Bathroom:  Separate Common  2 bathroom

f. Lighting facility: Electricity Oil/Lamp Kerosene/Gas

g. Drainage: Open Closed

 II. Drinking Water

a. Storage:  Refrigerator Covered Uncovered

III. Water Supply: Hand Pump Tap/CNWD Deep Well

Others: CNWD & Pump
IV. Toilet Facilities
 Owned Public/Communal Open field
Shared “Balot System” Others: __________________
V. Garbage Disposal
Composting Burning  Burying Collected
Garbage Truck Others: __________________
VI. Presence of Animals and Numbers:
 Dog Cat Pig Others: Chicken Numbers: 3
dogs and 4 chickens
VII. General Surrounding: Clean Dirty

3. FAMILY COMPOSITION

RELATIONSHIP
HEALTH IMMUNIZATION
SN NAME WITH HEAD OF AGE SEX OCCUPATION/EDUCATION STATUS STATUS
FAMILY

1 Ernesto Abordo Father in law 55 M Fisherman/High School High Blood

2 Yolanda Abordo Mother in law 48 F Store owner Healthy
3 Arman Abordo Husband 31 M Police Officer Healthy
4 Amber Joy Abordo Daughter 5 F Kinder Healthy
5

10

11

12

4. TRANSPORT AND COMMUNICATION FACILITIES

Owned: Yes  No
Tricycle Bicycle Padyak Bus Taxi
Car Jeep

Telephone
Television
Radio
 Newspaper/Magazine
 Cellphone

5. LANGUAGE KNOWN
Tagalog Ilocano Bicol
English Bisaya Any Other: _________________

6. A. NUTRITIONAL PATTERN
_ VEGETARIAN _ NON-VEGETARIAN
Staple Food:  Rice Wheat Ragi Mixed
Vegetables: Grown  Purchased Quantity used per day:
Milk: 1 Quantity used per day: once a day
Non-vegetarian dish: Specify: How often:

B. NUTRITIONAL STATUS OF FAMILY MEMBERS

Name of member Nourished/under nourished BMI Remarks

HEIGH
AGE WEIGHT
T

105 170cm Obese

Ernesto Abordo 55

68 150 cm Overweight
Yolanda Abordo 48

Arman Abordo 31 74 163 cm Overweight

Amber JoY Abordo 5

21 131 cm Normal

- When was the last time you visited the doctor/health center for a routine check-up?
Within the last 12 months Within the last 2 years
Between 2-5 years Over 5 years ago
I have never had a routine check-up/visit
- Are you able to visit a doctor/health care worker when needed?
 Always Sometimes Seldom Never
- Which of the following have stopped you from getting the health care you need? (Check all that
apply)
 Too expensive
Lack of transportation
Health worker is not attending
Others, please specify: ________________________________
 7. RECORD OF PAST ILLNESS (FOR THE PAST YEAR)
INVESTIGATIO
ILLNESS/CONDITIO DURATIO
NAME AGE CHECK-UP N TREATMENT
N N
DONE
YES NO

NONE

- Select any of the following preventive procedures you have had in the last year.
Vaccination, please specify
BP Check-up Prostate screen
Cholesterol screen Dental cleaning
Blood Sugar check Mammogram
ECG Colon/Rectal Examination
Vision screening  Pap smear
Hearing screening Others, please specify _________________

8. CURRENTLY PREGNANT WOMAN

I. PROFILE
Name: Contact Number:
Age: Occupation: Educational Attainment:

II. GENERAL HEALTH STATUS

BP: HEIGHT: WEIGHT:
Tetanus Toxoid status
ImmunizationTT
TT1 TT2 TT3 TT4 REMARKS
5
DATE GIVEN

Other immunization, please specify:

Any current medical condition/sickness:
Any health concern:

III. OBSTETRIC HISTORY

1. Number of pregnancies: 2
2. Number of preterm deliveries: 1
3. Number of full-term deliveries: 1
4. Numbers of still births: 0
5. Number of live births: 1
6. Number of abortions: 0 (spontaneous) (induced)
7. Number of ectopic pregnancies: 0
 Length of Normal (N) or Complications with
Child Date of Birth Sex
Labor Caesarian (CS) pregnancy or delivery
Amber Joy 9/29/2005 F 1 day CS Over due

IV. MENSTRUAL AND GYNECOLOGICAL HISTORY

1. Are your periods regular?  YES __ NO
2. Do you have spotting in between your menstruation? __ YES NO
3. Age at first menstrual period 12
4. Number of days from the first day of menstruation to the last day of next period (menstrual
cycle) in days: 28
5. Length/duration of menstrual flow: 5 days
6. Is your menstrual flow ____ LIGHT _____ MODERATE  HEAVY
7. Are your periods painful?  YES __ NO
8. Do you have any other symptoms/manifestations with your period?  YES __ NO
If yes, what are they? Pimples, headache, breast pain, stomach cramps
9. Have you had any pap smear test?  YES __ NO
If YES, when? LAST YEAR
What was the diagnosis? ______________________________________
How are you treated?
___________________________________________________________________________
___________________________________________________________________________
IF NOT PREGNANT:
10. Are you currently using contraceptive or birth spacing method? __ YES NO
If YES, what method are you using? __________________________________
If NO, have you ever used any contraception or birth spacing method in the past?
 YES __ NO
If YES, what method are you using in the past? PILLS
Why are you not using it now? GETTING FAT

If NO, why have you not used a contraceptive or birth spacing method? _____________
________________________________________________________________________
________________________________________________________________________

9. HEALTH
a. Where do you go if you or any of your family member is sick? Clinic
b. Who do you consult when you or any of your family member is sick? Doctor
c. When was the last time you or any of your family member had consultation/visit to the
doctor? For what reason: March 16, 2021/ TONSILITIS & UTI
d. When was the last time you or any of your family member visit a dentist? 2012
e. Is there any medication that is currently being taken by you or any of your family member?
If YES, please name them: NONE
f. Is any member of the family currently with sickness or condition? ___ YES  NO

What is the sickness/medical condition?

h. Is there death in the family for the past year? ___YES  NO
If YES, for what reason? _________________________________________________________
i. Have you attended any health-related meetings or seminar? ___ YES NO
If YES, what is the topic? __________________________________________________________
If NO, what is the reason why you don’t attend a health-related seminar, meetings, and the like?

j. Which of the following do you think are the FIVE most important factor a healthy community? Please
check 5 only.

 Child care
_____ Prenatal/Postnatal care
_____ Low death rate
_____ Low illness rate
 Healthy behavior and lifestyle
__ Healthy food sources
 Clean and safe environment
 low level of child abuse
 Emergency and disaster preparedness
Others, please specify: ___________________________________________________________

Prepared by:

Regala, Bianca Ysabelle M.

Student

Art Z. Tribunal, RN, LPT

Instructor