FAMILY HEALTH SERVICE AND PROGRESS RECORD

Head of the Family _________________________________________________________ Family NO. _____________________

Address ____________________________________________________________________________________________________________________
I. Assessment of the family, Home and Environmental Condition

A1. Members of the Household

Relation Educational Remarks/
Sex Birthday age Religion Occupation
Family Member to Head Attainment Date Entered
Type of Monthly
Place
work Salary
No. Name

A2. Members not residing in the household but affect family resources generation and use

Relation Educational Remarks/

Sex Birthday Age Religion Occupation
Family Member to Head Attainment Date Entered
Type of monthly
Place
work salary
Name
①
A. Home and Environment
Date Assessed: _______________________________________
1. Home
a. Ownership ( ) owned ( ) rented rent free ( )
b. contruction materials ( ) wood/bamboo ( )concrete ( ) mixed ; wood /concrete
c. Number of rooms used for sleeping _________________
d. Lighting facilities ( ) electricity ( ) kerosense others specify _____________________________
e. General sanitary condition _______________________________________________________________________

2. Drinking Water Supply

Source : ( ) private_______________ ( ) public ______________ Potability _______________________
Distance from the house ______________________________________________ meters
Storage : ( ) none direct from faucet ( ) container with cover ( )container w/o cover others specify __________________

3. Kitchen
Cooking Facility ( ) electric stove ( ) gas stove ( ) fire wood/charcoal
Sanitary Condtion ___________________________________________________________________________________
Drainage facility ( ) open ( ) covered ( ) none

4. Waste Disposal
a. Refuse and Garbage
Container ( ) covered ( ) open ( ) none
Method of Disposal
( ) hog feeding ( ) open burning
( ) open dumping ( ) garbage collection How many times a week _______________
( ) pit ( ) others specify ___________________
( ) composting

b. Toilet Facility
type ( ) none
( ) water sealed ( ) flush ( ) buhos
( ) pit privy ( ) covered ( ) w/o covered
others specify _________________________________________
distance from the house _____________________________ meters
Sanitary condition ___________________________________
②
5. Domestic Animals
Kind Number Where Kept Vaccine

6. The Community in General

a. General sanitary condition ____________________________________________
b. Housing congestion ( ) yes ( ) no
c. Presence of breeding sites of vectors of disease ( ) yes; spcify ( ) None
d. Recreational Facilities : _______________________________________________________________________
e. Availabilty of health care facilities / services; Describe briefly _____________________________________________________________
______________________________________________________________________________________________________________________
f. Distance of the house from the nearest health care facility ______________________________________________________________

B. Socio-economic
Average monthly income in peso Average
1,000.00 - 5,000.00 ( ) 1,000.00 - 5,000.00 ( )
5,001.00 - 10,000.00 ( ) 5,001.00 - 10,000.00( )
10,001.00 - 15,000.00 ( ) 10,001.00 - 15,000.00
( )
15,001.00 - 20,000.00 ( ) 15,001.00 - 20,000.00
( )
20,001.00 - 25,000.00 ( ) 20,001.00 - 25,000.00
( )
25, 001.00 - 30,000.00 ( ) 25, 001.00 - 30,000.00
( )
30,001.00 - 35,000.00 ( ) 30,001.00 - 35,000.00
( )
35,001.00 - 40,000.00 ( ) 35,001.00 - 40,000.00
( )
40,001.00 -45,000.00 ( ) 40,001.00 -45,000.00( )
45,001.00 - 50,000,00 ( ) 45,001.00 - 50,000,00
( )
above 50,000.00 ( ) above 50,000.00 ( )
③
Amount
Breakdown of expenses in peso Recreational Activity
1. food 1 _______________
2. education 2 _______________
3. house rentals 3 _______________
4. medication 4 _______________
5. leisure 5 _______________
6. water 6 _______________
7. electricity 7 _______________
8. amortization 8 _______________
9. clothing 9 _______________
10. others 10 _______________

C. Health Condition
1. Maternal and Child Health
Immuniza
Immuniza Date tion Place of
a. AP tion Given Status Delivery Remarks
Name of mother B-day LMP EDC GPA TT 1
TT 2
TT 3
TT 4
TT 5

Any Pathological Condtion current status Medication

Elevated B/P ( ) treated ( ) _____________________________________________________
history of eclampsia ( ) ongoing ( ) _____________________________________________________
diabetes/hisotry if diabeted ( ) no action taken ( ) Reason ______________________________________________
history of urinary tract infection ( )
anemia ( )
PTB ( )
any respiratorydisease ( )
 Diagnostic Laboraotry done OB Assessment Date Remarks
CBC ( ) B/P _________________
weight _________________
hg,hct ( ) FHB _________________
④ urinalysis ( ) fundic height _________________
FBS ( )
RBS ( )

b. Post Partum
Birth OB HX
Name of Mother Birthday Date of Delivery Place of Delivery Attendant Child Sex GPA Remarks

c. Immunization ( EPI) 12 months and below

immuniza
Date Where tions
Name of the child Birthday sex weight immunization Given Given status Remarks
BCG
DPT1
DPT 2
DPT 3
OPV 1
OPV 2
OPV 3
Hepa 1
Hepa 2
Hepa 3
 d. Nutritional status 6 years old and belowage as of last
Name of the child birthday birthdY Weight Date Taken Remarks

❺
Family Planning
method where health care
Spouses Name CS BD Age used availed provider years of use Remarks

e. Health status Causes of

common causes of illness for the death for
past 2 years Remarks the past 5 Remarks