FAMILY HEALTH ASSESSMENT GUIDE 1

I. GENERAL DATA
Family Name : CABADING
Name of Barangay : LUMBO
Name of Purok : PUROK 9A
Household No : PHASE2 BLOCK 5 LOT 21

II. FAMILY DATA

Length of residency : 15 YEARS
Place of origin : VALENCIA CITY, BUKIDNON
Family size : 5
Religion :IGLESIA NI CRISTO
Husband : GUILLERMO G. CABADING JR.
Wife : RAQUEL S. CABADING
FAMILY MEMBER’S CHART

Marital Highest
Name Relation to Sex Date of Birth Age Status Education Occupation
Head

Month Day Year Type of work Place

GUILLERMO G. CABADING Head M September 09 1973 47 Marrie College Construction Valencia City,
JR. d Graduate stock manager Bukidnon
RAQUEL S. CABADING Wife F November 30 1976 44 Marrie College Government Valencia City,
d Graduate employee Bukidnon
HYACINTH ANNE S. Daughter F August 25 1998 22 Single College Self-employed Valencia City,
CABADING Graduate Bukidnon
HANNAH ANGELU S. Daughter F July 26 1999 21 Single College level Student Valencia City,
CABADING Bukidnon
HAYWOOD ANDREU S. Son M May 13 2003 17 Single Senior High Student Valencia City,
CABADING School Bukidnon
 III. FAMILY CHARACTERISTICS

1. Type of Family Structure

( ) Extended ( ) Matriarchal ( ) Dominant family member ( ∕ ) Nuclear ()
Patriarchal

2. General Family Relationship/Dynamics

CRITERIA STATUS ADDITIONAL
INFORMATION
Observable conflicts between family members NONE
Characteristics of communication EXCELLENT
Interaction patterns among members BONDING

3. Monthly Family Income Source

Husband: _____________ Wife: ________________ Others: ________________
( ) P 3, 000.00 and below ________ ( ) P16, 000 – P20,000.00
( ) P 4, 000.00 – P10, 000.00 ________ ( ∕ ) P 20, 000 and above_________
( ) P 11, 000.00 – P15, 000.00 ________

4. Family member heading on decision making? FATHER

IV. HOME AND ENVIRONMENT

1. House

A. Ownership: ( ∕ ) Owned ( ) Rented ( ) Others

B. Type of housing
( ) wood ( ) concrete ( ∕ ) mixed ( ) makeshift ( ) others, specify ________
C. Number of rooms used for sleeping: 2 rooms
D. Furniture: ( ) None ( ) Limited ( ∕ ) Adequate
E. Home appliances present: Television and refrigerator.
F. Lighting Facilities: ( ∕ ) Electricity ( ) Kerosene ( ) Others, specify
G. Safety Hazards: ( ) Loose, rickety stairs ( ) Loose doors, walls, post
Windows: ( ) None ( ) only 1 ( ∕ ) more than 1
Sharps and matches within reach of children? ( ) Yes ( ∕ ) No
Soft drinks bottles used as kerosene container? ( ) Yes ( ∕ ) No
Medicine and poisonous substances kept side by side? ( ) yes ( ∕ ) No
H. Is the living space adequate? ( ∕ ) yes ( ) no
2. Food Storage/Cooking Facilities
A. Food storage and handling (for left over)
( ∕ ) Covered ( ∕ ) Given to animals
( ) Not covered ( ) Others, pls. specify ________________________
B. Cooking facilities
( ∕ ) Fire wood ( ) LPG fueled
( ) Kerosene/stove (/ ) Electric stove

3. Water Facility
A. Source of water supply
( ) spring ( ) water well/closed ( ) bought
( ∕ ) water district ( ) open/artesian ( ) others, specify _______________
B. Water source ownership
( ) Shared ( ) Owned ( ∕ ) Provided by the government ( ) Others
C. Drinking water storage
( ∕ ) Covered ( ) Uncovered ( ) faucet
( ) Owned ( ) Shared ( ∕ ) refrigerated
D. Containers used
( ∕ ) plastic pitchers ( ) bottles ( ) jars, clay pots ( ∕ ) others, pls. specify Water Dispenser
E. Distance of comfort room from the water source:
 4. Waste Management
A. Garbage
1. Type of garbage disposal
( ) collected _________ (/) burning (/ ) waste segregation
( ) burying ( ) feeding to animals ( ) open dumping
( ) throw in the river/sewer ( ∕ ) garbage can ( ) others, pls. specify____________

2. Waste segregation method: ( ∕ ) yes ( ) no

If yes, specify method: Compost pit
3. Do you recycle garbage? ( ∕ ) yes ( ) no
If yes, specify how: compost pit

B. Toilet
1. Toilet ownership: ( ) shared ( ∕ ) owned ( ) others, pls. specify
__________
2. Type of waste disposal:
( ∕ ) flush ( ) water-sealed ( ) pit privy ( ) antipolo
( ) cat hole ( ) others, please specify: __________________________________

5. Premises indication
A. Type of drainage system: ( ) open ( ∕ ) close
B. Drainage
( ) Present ( ) None ( ∕ ) Covered
( ) Uncovered ( ) Others, pls specify _______________________________
Frequency of cleaning
( ∕ ) Daily ( ) weekly ( ) Monthly
( ) Yearly ( ) Others, pls specify
_____________________________
C. Breeding places
( ∕ ) Present ( ) None ( ) others, pls specify________
Methods used to control breeding places
( ) Fogging ( ∕ ) Mosquito net ( ∕ ) Insecticides
( ) None ( ) Others, pls specify_________________________
Frequency of method used
( ∕ ) Daily ( ) Monthly ( ) weekly
( ) Yearly ( ) Others, please specify __________________________

D. Pets/animals kept in the yard/home

Dogs and Cats

6. Plants/Vegetation
A. Plants in the surroundings
( ∕ ) Vegetable ( ∕ ) Herbal ( ) Ornamental
B. List kinds of vegetable plant found in the surroundings ) eggplants, okra, squash, sayote,
camote tops and malunggay.
C. Information on the herbal plants approved by DOH? ( ∕ ) Yes ( ) No
If yes, please fill up the table below:

HERBAL PLANT INDICATION METHOD OF USE

Lagundi Cough Boiled in water (drink)
Mayana Cough Boiled in water (drink)
Gabun Cough Boiled in water (drink)
 V. HEALTH AND HEALTH PRACTICES

1. Common illnesses encountered for the last 6 months and the treatment applied.
NAME COMMON ILLNESS TREATMENT
Guillermo G. Cabading Jr. Cold/Cough Drinking of lemon juice and
Lagundi and also taking
medication like neozep.
Raquel S. Cabading Headache Water therapy and taking
medication like rexidol.
Hannah Angelu S. Cabading Fever Drinking of lemon juice and
taking medication like
paracetamol

2. Whom do you consult for health-related problems?

( ∕ ) hilot ( ) midwife (/ ) doctor ( ) albularyo
( ) barangay health worker ( ) rural health center ( ) nurse ( ) others __________
3. Delivery system: ( ) home ( ∕ ) hospital ( ) clinic ( )others ___________
4. Availability/Utilization of health services: ( ∕ ) Yes ( ) No, Why________________
5. Health personnel feedback ( ∕ ) Friendly ( ) Unfriendly
6. Immunization status of family members
A. Are you aware of immunization program? ( ∕ ) Yes ( ) No
If No, specify reasons: _______________________________________________________
B. How were you informed of the program?
( ) Radio ( ∕ ) Barangay Health Center ( ) TV
( ) Midwife ( ) others, specify ___________________________________________
C. Are your children immunized? (ages 0 – 2 ) ( ∕ ) Yes ( ) No
If no, specify reasons? _______________________________________________________
If yes, fill up the chart below:

COMPLETE/INCOMPLETE OR NO
NAME OF CHILD AGE IMMUNIZATION
Hyacinth Anne 22 Bakuna/Polio immunization
Hannah Angelu 21 Bakuna/Polio immunization
Haywood Andreu 17 Bakuna/Polio immunization

D. Place where the child obtains immunization inoculation?

( ∕ ) Barangay Health Center ( ) Clinic ( ) Hospital ( ) Others __________
E. Do you know the diseases a child would acquire if not immunized? ( ∕ ) Yes ( ) No
If yes, specify the disease measles, mumps, meningitis and polio
F. Do you know the symptoms and side effects after the child get immunized? ( ) Yes ( ∕ ) No If
yes, what measures taken to ease the effect of the vaccines? .
G. Did you pay for the vaccines? ( ) Yes ( ∕ ) No

7. NUTRITION
 A. Children 0-5 years

AGE IN DATE OF NUTRITION

NAME OF CHILD MONTHS WEIGH HEIGHT BIRTH STATUS
T

B. Food given to children 0-2 years:

( ) breastmilk ( ) milk formula ( ) mixed feeding – (BF +) ( ) Others,
specify:__________
C. Type of infant formula used:
___________________________________________________
D. How they clean their feeding bottle?
_____________________________________________
E. What supplementary foods do they give to the child? _______________________________
F. Does Vitamin A give to children of 12 – 59 mos.? ( ) Yes ( ) No
If yes, when was the last vitamin given? Month’s __________ Year ________

8. PREGNANCY

LAST NUMBER
NAME OF MENSTRUAL AGE OF TETANUS NUMBER OF OF
PREGNANT PERIOD PREGNANC TOXOID PREGNANC PRENATAL
WOMAN Y Y VISITS

A. Did you experience miscarriage? ( ) Yes ( ) No

If yes, specify the reason? __________________________________________________
B. Where do you go for prenatal? ( ) Health Center ( ) Therapist
( ) Doctor ( ) Others, specify__________
9. FAMILY PLANNING

A. Were you informed about family planning? ( ∕ ) Yes ( ) No

If No, Specify_______________________________________________________________
B. Where did you get the information?
( ∕ ) BHW/Health Center
( ) Government offices Name: _________________________
( ) Private Agencies Name: _________________________
( ∕ ) Media
[ ∕ ] TV
[ ] Radio
[ ] Press
( ) others (please specify)
______________________________________________________

C. What kind of Family planning method did you use?

( ) IUD ( ) Pills ( ) Condom ( ) Ligation ( ) Vasectomy ( ) Injectables
( ) Calendar Method ( ) LAM ( ) others (please specify) _________

D. How long have you been using the family planning method? ______________
 E. Was there any significant effect you felt as you used this kind of method? ( ) Yes (/ ) No
If yes, please specify below:
___________________________ ___________________________
___________________________ ___________________________
___________________________ ___________________________
10. Have you had adequate
A. rest and sleep? __∕__ (yes) _____ (no)
B. exercise? __∕__ (yes) _____ (no)
C. relaxation activities? ____ (yes) __∕___ (no)
D. stress management activities? __∕__ (yes) _____ (no)

11. Felt Family Needs (Identify and rank according to priority

FAMILY NEEDS PRIORITY

1. Food 2
2. Medicines 4
3. Shelter 3
4. Clothes 5
5. Finance 1
6.
7.
8.

VI. ENVIRONMENT

1. Kind of Neighborhood Good

2. Social and Health facilities available Barangay Health Clinic/Center
3. Communication and Transportation Cellphones, motorcycles and Four wheels
facilities

VII. AWARENESS OF COMMUNITY ORGANIZATION

A. Are you aware of existing organizations in the community? ( ) yes ( /) no

B. Name all the organization/s you know.

C. Are you a member of any of these organizations? ( ) yes (/) no

D. Are you aware of its activities and projects? ( ) yes ( /) no
E. How are you involved in its activities?
( ) attend meetings ( ) planning ( ) implementation ( ) evaluation
( ) give donations ( ) others, specify ______________________________
F. Name 5 formal and informal leader of the community whom you think can lead the people.

1. Barangay Captain
2. Purok Leaders
3. Barangay Councelors
4. SK Chairman
5. SK kagawad

VIII. HEALTH INSURANCE

A. Information about Health Insurance ( ∕ ) Yes ( ) No
If yes, where the information obtained
( ∕ ) Government agency Name: Philhealth
( ) Private agency
( ∕ ) Media ( ) Others, specify ________________________
[ ∕ ] TV
[ ∕ ] Radio
[ ∕ ] Barangay Health Center

B. Do they have Health Insurance? ( ∕ ) Yes ( ) No

If No, please specify reasons and their plan to obtain health insurance: ______________