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: Raymond Sanglay Contact Number: 09186816981

Primary Health Center: Rural Health Unit (Jose Panganiban)
Address: Purok-3 Brgy. Plaridel, Jose Panganiban Camarines Norte
Interviewed by: Patricia Anne S. Rojas Date of interview: March 3, 2021
(Name of Student)

1. IDENTIFICATION INFORMATION
Head of Family: Raymond Sanglay

Occupation: Meat and Frozen Foods owner Monthly Income: 18,000 – 20,000 pesos

Address: Purok-3 Brgy. Plaridel, Jose Panganiban Camarines Norte

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: 30-40 years

Ethnicity: Asian

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: 4 rooms

b. Kitchen: Separate Part of the house

c. Fuel Used: LPG Kerosene Firewood Electricity

d. Ventilation: Number of windows: 6 Good (✓) Poor ( )

e. Bathroom: Separate Common

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

g. Drainage: Open Closed

 II. Drinking Water

a. Storage: Refrigerator Covered Uncovered

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

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

3. FAMILY COMPOSITION

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

1 Bella Sanglay Mother 72 F Retired Teacher Average Fully immunized

2 Glenda M. Sanglay Wife 46 F Housewife/Store owner Average Fully immunized
3 John Patrick M. Sanglay Son 15 M Student Excellent Fully immunized
4 Zia M. Sanglay Daughter 4 F Day care student Average Fully immunized
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: 1-3 kg gm/kg
Milk: Quantity used per day: half to whole liters
Non-vegetarian dish: Specify: chicken, meat, fish dishes How often: 2-3x per week

B. NUTRITIONAL STATUS OF FAMILY MEMBERS

Name of member Nourished/under nourished BMI Remarks

HEIGH
AGE WEIGHT
T
Bella Sanglay Overweight
72 58 kg 150 cm 25.78
Glenda M. Sanglay Overweight
46 61 kg 152 cm 26.40
John Patrick M. Sanglay Normal
15 64 kg 169 cm 22.41
Zia M. Sanglay Normal
4 16 kg 99 cm 16.2

- 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

Raymond Sanglay 54 High Blood 1 month November, 2020 ✓ Prescribed Medicine

Pressure
Glenda Sanglay 46 N/A N/A N/A N/A
Bella Sanglay 72 Hypertension 3 weeks January, 2021 ✓ Diuretics
John Patrick Sanglay 15 Colds 1 week February, 2021 ✓ Prescribed Medicine
Zia M. Sanglay 4 Asthma attack 5 days December, 2020 ✓ Prescribed Medicine

- Select any of the following preventive procedures you have had in the last year.
Vaccination, please specify Anti-rabies
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: N/A Contact Number: N/A
Age: N/A Occupation: N/A Educational Attainment: N/A

II. GENERAL HEALTH STATUS

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

Other immunization, please specify: N/A

Any current medical condition/sickness: N/A
Any health concern: N/A

III. OBSTETRIC HISTORY

 1. Number of pregnancies: N/A
2. Number of preterm deliveries: N/A
3. Number of full-term deliveries: N/A
4. Numbers of still births: N/A
5. Number of live births: N/A
6. Number of abortions: N/A (spontaneous) N/A (induced) N/A
7. Number of ectopic pregnancies: N/A

Length of Normal (N) or Complications with

Child Date of Birth Sex
Labor Caesarian (CS) pregnancy or delivery

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 ___
4. Number of days from the first day of menstruation to the last day of next period (menstrual
cycle) in days: _________
5. Length/duration of menstrual flow: _______ 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? ______________________________
9. Have you had any pap smear test? __ YES __ NO
If YES, when? _______________________________________________
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? _________________________________
Why are you not using it now? ______________________________________________
________________________________________________________________________
________________________________________________________________________

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? Hospital, if necessary.
 b. Who do you consult when you or any of your family member is sick? Physician
c. When was the last time you or any of your family member had consultation/visit to the
doctor? December 2020. For what reason: Follow-up checkup.
d. When was the last time you or any of your family member visit a dentist? January 2021.
e. Is there any medication that is currently being taken by you or any of your family member?
If YES, please name them: Losartan, Aspirin, Tapazole.
f. Is any member of the family currently with sickness or condition? ✓ YES _____ NO

What is the sickness/medical condition? Cough and colds.

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?
Not aware that there was a seminar going on at that moment.
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:

Gabriel Mathew S. Largo

Student

Art Z. Tribunal, RN, LPT

Instructor