FAMILY HEALTH ASSESSMENT FORM

FAMILY SURNAME:____TABIOS, DURAN_______________________________

HOUSE NO: ______________________ STREET:___________ZONE 3_________________
BARANGAY: ____NAPALIONG__________ DISTRICT:____________04____________
MUNICIPALITY/CITY: ______JONES______ CONTACT NO:________09976186219_________
SOURCE (S) OF INFORMATION:______________________
DATA GATHERED BY:________________________ DATE:_____________________

TYPE OF FAMILY
 Based on composition
 Based on Locus of Power
 Based on Place of residence

HOUSEHOLD MEMBERS

NAME AGE RELATIONSHIP TO THE HEAD

OF THE FAMILY
Tabios, Florence 48 Mother( Sister of my Auntie)
Duran, Teofisto 55 Uncle
Duran, Eva 54 Auntie
Duran, Marjorie 18 Couzin
Velasco, John Alexis 7 Nephew
Velasco, David 12 Nephew

Grand
mother
Note: Insert genogram, family health tree, and ecomap

Genogram

Grand Grand
mother Father

(M) (F)
(F) Eva 54 Teofist
(M)
+Guiller o 55
Florenc
mo
e 48

Bonna
20 Kristine Marjori
32 e 18

John Davi
7 d 12
Family health Tree

GRAND MOTHER GRAND FATHER

Aggasid, Eutiquio A. Aggasid, Emma G.

Complications in lung Bone Cancer

Eva Duran ( Mother )

Boy Aggasid Ronaldo Eizel Aggasid
Jojo Aggasid
54 Florence Aggasid
52 39
Aggasid 38
Anemic 45
48 Asthma

Latent TB

Guillermo Tabios ( +)

70

Asthma ,Motor Accident,

Gastrointestinal

Bonna Tabios 20

Weak Lungs
 ECOMAP

Health Church
Services

Social
Services

Housing

( Residential
Teofisto
Eva Florenc )
e 48
( Uncle) ( Sister )
(Auntie)
Mother

Utility
services
John David
Alexis 7 12 Bonna
( Grand ( Grand 20 Overseas
child ) Child ) ( Nephe
w) Filipino
Worker
Marjori
e 18
( Daugth
er )

Divorced Parents

Father
( Deceased)

Single
Parent
School family
FAMILY CHARACTERISTICS
FAMILY MEMBERS LIVING OUTSIDE THE HOUSEHOLD
Name,age and relationship to head of household

 Aggasid, Jojo ( Uncle) 38

 Aggasid Ronaldo ( Uncle ) 45
 Aggasid, Eizel ( Auntie) 39
 Aggasid, Boy ( Uncle ) 52
Location of family member
 Ilocos Norte
 Cagayan
Frequency and duration of contact

 Mobile Phone
Means of communication

FAMILY MOBILITY
Length of time at current address

 5 years
Address of previous residence

 Brgy 3, San Nicolas, Ilocos Norte

Frequency of geographic moves
 Twice ( From Manila for 3 years, 12 years in Ilocos and 4 years here in Isabela )
FAMILY DYNAMICS
Emotional bonding of family members


Distribution of authority and power
 Believing in the principle that all people are equal and deserve equal
rights and opportunities. ( Egalitarian Family )
Degree of individual autonomy
 80% degree of autonomy that we can make our own decisions as their children
How members communicate

 Inside the house we communicate properly through in dining area, in this area we
will talk about all important matters in the family
 Outside family members is through a phone call or video call
How decisions are made
 We can decide for ourselves but inside the house rules my auntie and uncle should
 be the one to be follow

How problems are solve

 Problems are solve, by communication within the family

How conflict is handled

 The conflict inside the family handled through a good communication to everyone.
Division of labor

 Girls should be the one to cook and do household chores while the head of the
family is concern in our farm.

SOCIOECONOMIC AND CULTURAL CHARACTERISTICS

FAMILY SOCIAL INTEGRATION

Languages or dialects spoken
 Ilocano, Tagalog

Literacy ( Ability to read or write in language)

 Every member has the ability to read and right

Degree of social network with friends, neighbors, and other relatives
 Facebook
 Messenger

Network with religious organization

 Churches

Network with social organization

 Family
 Clan
Educational Experiences

 My mother side family, the graduated high school level only

Work history


Adequacy of financial resources

 Salary of my other and cousin

 Farm
Leisure time interest
 Watching Tv
 Playing mobile phones

CULTURAL INFLUENCES: VALUES, ATTITIUDES, AND BELIEFS ABOUT:

Spirituality

 Going to the church every Sunday

Rituals (holidays and celebrations)
 NONE

Dietary Habits

 NONE
Health
 My mother side believe in evil spirits who cause sickness to the family

Folk diseases
 None

Traditional healers
 ALBULARYOS

FAMILY ENVIRONMENT
FAMILY RESIDENCE
Adequacy of size

Structural safety

Water sanitation
 Yes
Food preparation and storage
 We always sanitize our hands before preparing foods .

Sewage

 NONE
Garbage disposal

 NONE
Excreta disposal
  NONE
Pest and vermin control

 NONE

FAMILY NEIGHBORHOOD
Location ( e.g. urban or rural, subdivision , slum area)

 RURAL
Type ( e.g. residential , semicommercial)

 RESIDENTIAL
Safety
Traffic patterns
Lighting
Security

Population density ( crowding)

 Not crowding a place

Sources of pollution
Air
Water
Soil
Noise

FAMILY HEALTH AND HEALTH BEHAVIOURS

Activities of daily living ( how a family spends a typical day )

 Doing Household
 Sleeping
 Teaching their grand children
 Using phones
Health history (pregnancy, illness, death within the past 5 years / health attendance)
 NONE

Self-care ( health promotion and disease prevention)

 SANITATION
 CONTROLING OF FOODS

Risk behaviors

 NONE
Health status ( problems and priorities)
 NONE
Home remedies
 Lagundi
 Bayabas

Health care resources

Health workers
Health agencies