FAMILY HEALTH ASSESSMENT FORM

Health District No.: ___________________________ Barangay No.:______________________

Zone No.: ___________________________________ Family No.:_________________________
Head of the Family: ___________________________
Address: ____________________________________
I. FAMILY STRUCTURE AND CHARACTERISTICS II. SOCIO-ECONOMIC AND CULTURAL FACTORS

Name of Family Civil Ethnic

Position Age Gender Religion Education Occupation Remarks
Member Status Background
 III. HOME LIVING & ENVIRONMENTAL B. Water Supply E. Toilet Facility
CONDITION: 1. Source: 1. Type of Toilet:
A. Housing O NAWASA O Water Sealed
O Deep Well O Pit Privy
1. House Ownership: O Others:________________ O Septic Tank
O Owned 2. Ownership: O Others:________________
O Rent O Private 2. Ownership:
O Rented Free O Public O Owned
O Shared O Shared
2. Type of House: 3. Drinking Storage: 3. Sanitary Condition:
O Strong O Jar O Sanitary
O Mixed O Covered O Unsanitary
O Light O Uncovered F. Domestic Animals
O Drum 1. Kind: _____________________
3. Number of Rooms: _________ O Bottles 2. Cage:
C. Kitchen O With
4. Privacy: 1. Cooking Facility: O Without
O With O Gas Stove G. Insect & Vermin Control
O Without O Charcoal O Mechanical
O Electric Stove O Chemical
5. Lighting: O Others:_________________ O Environmental
O With Electricity’ 2. Drainage Facility: O Others:_______________________
O Without Electricity O Open H. The Community in General
O Other: ________________ O Blind 1. General Sanitary Condition:
O None ________________________________
6. Ventilation: D. Garbage Disposal 2. Housing Congestion:
O Satisfactory 1. Reused Disposal: O Yes
O Fair O Collected O No
O Poor O Burning 3. Recreational Facilities: ______________
O Burying 4. Availability/ Accessibility of Health Care Facility
7. General Sanitary Condition: O Open Dumping (Describe Briefly):
O Good 2. Garbage Container:
O Fair O Open
O Poor O Covered
O None
IV. HEALTH AND MEDICAL HISTORY 4. Source of Medical Care
1. Present Illness:
Regarding Pregnancy and Lactation:
O Health Center
O Hospital
O Private Physician
O Private Clinic
O Others:_______________________
5. Nutrition:
a. Infant Feeding: O Breastfed O Bottlefed O Mixed Feeding
b. Type of Milk: O Powdered O Evaporated
c. Age Supplemental Feeding Started:__________________
d. Type of Foods Given: _____________________________
_______________________________________________
6. Food beliefs regarding Pregnancy and Lactation:
a. Foods not given during pregnancy: ____________________
________________________________________________
________________________________________________
b. Foods not given to mother during lactation: ______________
________________________________________________
________________________________________________
c. Foods and drinks given to mother during pregnancy &
lactation: ________________________________________
________________________________________________
________________________________________________
7. Food Preference and habits of the family: ________________
______________________________________________________
______________________________________________________
 Medical
Name Disease Suffered Remarks
Attendance

2. Past Illness:
Medical
Name Disease Suffered Remarks
Attendance

3. Immunization Status of Children

Disease
Name Vaccines Given Remarks
Suffered
Family: Date: FORMAT: Plan of Visit
Address: Health Dept.:
Assessed Justification
Family Coping Areas Point Scale
Problems Statements
Physical
1 2 3 4 5
Independence

Therapeutic
1 2 3 4 5
Competence

Knowledge of health
1 2 3 4 5
condition
Application of
Principles of General 1 2 3 4 5
Hygiene

Health Attitudes 1 2 3 4 5

Emotional
1 2 3 4 5
Competence

Family Living 1 2 3 4 5

Physical Environment 1 2 3 4 5

Use of Community
1 2 3 4 5
Resources

Comments:

Nurse’s Signature: