Community Health Nursing

Family Assessment Guide Form

MCH ES NTP EPI NP

MCH ES NTP EPI NP
Barangay

GREEN: Safe
RED: Danger
YELLOW: Improving
BLUE: Not Applicable

A. GENERAL INFORMATION
1. FAMILY DATA

Family Name: __________________________ Address: ______________________________

Barangay House No: _______________

Length of residency: _______________ ( ) Permanent ( ) Transient
Place of origin: Husband: ________________________ Wife: ____________________________
Family size: ( ) 1-3 small ( ) 4-6 Medium ( ) 7 or more Large
Religion: Husband: __________________________ Wife: _____________________________

2. Family Members` Chart

Relationship
Civil to the Educational
Family Member Birthday Age sex Religion Occupation
Status Family Attainment
Head
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Relationship
Family Member Civil Educational
Birthday Age sex Religion to the Family Occupation
(for Extended Family) Status Attainment
Head
1.
2.
3.
4.
5.
6.
7.
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 8.
9.

Legend:
Civil Status: Educational Attainment Occupation Status
W – Widow NA – not applicable (0-2 yrs. old) NA- Not Applicable (0-14 y/0)
S- Single PE- Pre-elementary (Nursery to Prep) SE- Self Employed
M- Married EL – Elementary Level E- Employed
Se- Separated EG – Elementary Graduate U- Unemployed
C- Child (0-14 y/o) NFE – No Formal Education R- Retired
HSL –High School Level
HSG – High School Graduate
CL – College Level
CG – College Graduate
NYS – Not yet studying

3. FAMILY CHARACTERISTICS
a. Type of Family Structure
A. Traditional: Extended ______________ Nuclear ______________
B. Non-Traditional : Single Parenthood __________ Others, specify _______________

b. Stages of Family Development ( Please check )

_________Beginning Family ____________ with Teenagers
_________ Early Childhood ____________ Launching Family
_________ With Pre-schooler ____________ Middle Aged Family
_________ With Schooler ____________ Aging Family

B. SOCIO-ECONOMIC PROFILE
C.
1. Language Spoken ( Most Common Language used by the Family )
( ) Filipino ( ) Ilocano
( ) Visaya ( ) others, specify ________________________
2. Lot ownership
( ) owned ( ) rented
( ) free use ( ) others, specify ________________________
3. House Ownership
( ) owned ( ) rented
( ) free use ( ) others, specify ________________________

4. Types of Housing Materials

( ) wood ( ) semi-concrete
( ) concrete ( ) makeshift
( ) bamboo/ nipa ( ) others, specify ________________________

5. Power/ Lighting Source

( ) electricity ( ) kerosene
( ) LPG / lamp ( ) others, specify ________________________

6. Cooking Facility
( ) LPG ( ) charcoal
( ) wood ( ) electric range
( ) others, specify
________________________
7. Appliances Owned
( ) TV ( ) radio
( ) refrigerator ( ) others, specify ________________________

Skill Checklists for NEUST College of Nursing:

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 8. Monthly Family Income source
Husband: ________________________
Wife: _________________________
Others: _________________________

Member of the Occupation Place of Work Amount of Income Educational

family Attainment

Total Monthly Family Income Source: Check Bracket

Below P 5, 000 ____________ Above P 20,000 – 30,000 ____________
Above P 5,000 – 10,000 ___________ Above P 30,000 – 40,000 ____________
Above P 10,000 – 15,000 ___________ Above P 40,000 – 50,000 ____________
Above P1 5,000 – 20,000 __________ More than P 50,000 ____________
Income adequate to meet basic needs _______ Yes _______ No

9. Felt Family Needs ( Identify and rank according to priority)

1. 6.
2. 7.
3. 8.
4. 9.
5. 10.

D. ENVIRONMENTAL FACTORS

1. Adequate living space ( ) Yes ( ) No

2. Proper Lighting and ventilation ( ) Yes ( ) No

3. Types of Water supply

( ) owned ( ) shared
( ) bought ( ) others, specify ________________________

4. Source of Water supply

( ) open well ( ) pitcher pump
( ) piped water line pitcher pump ( ) pitcher pump with electric motor and faucet
( ) protected well FOR PITCHER PUMP ( ) Deep well (3 pipes above) ( ) Shallow (below 3 pipes)
( ) springs ( ) others, specify ________________________

5. Drinking water storage

( ) refrigerated ( ) covered
( ) uncovered ( ) others, specify ________________________

6. Containers used
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 ( ) plastic pitchers ( ) jars, clay, pots
( ) bottles ( ) others, specify ________________________

7. Food source
( ) market ( ) store
( ) vendor ( ) own produced

8. Garbage disposal

( ) collected ( ) burning
( ) waste segregation ( ) burying
( ) feeding to animals ( ) throw in the river / river sewer
( ) open dumping ( ) others, specify ________________________

9. Drainage system
( ) open ( ) closed ( ) none

10. Type of human waste disposal

( ) flush ( ) water-sealed
( ) wrap and throw ( ) pit privy
( ) others, specify ________________________

11. Toilet ownership ( ) owned ( ) shared ( ) none, specify ____________

12. Transportation Availed:

( ) tricycle ( ) jeepney
( ) bicycle ( ) hand-tractor
( ) others, specify ________________________

13. Common household pests found at home

a. .
b. .
c. .
d. .
e. .

14. Presence of breeding sites of insects, rodents ,etc ( ) Yes ( ) No

15. Pets/ animals kept in the yard / home

16. Presence of accidents hazards ( ) Yes, specify ( ) No

E. HEALTH AND HEALTH PRACTICES

1. Illnesses present in the family and current treatment regimen

Father : _____________________________________________________________________
Mother: _____________________________________________________________________
Children: ____________________________________________________________________

2. Common illnesses encountered for the last 6 months and treatment applied
Illness Treatment / Consultation
_______________ __________________________________
_______________ __________________________________
_______________ __________________________________
_______________ __________________________________

3. Mortality for the past 24 months: Any death in the family? _____ Yes _____ No

4. Causes of death of the family members for the past 24 months.

Name Cause of death
_____________________ _____________________
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 _____________________ ______________________
_____________________ ______________________

5. Whom do you consult for health related problems? ( ) government ( ) private

( ) manghihilot ( ) albularyo
( ) midwife ( ) nurse
( ) doctor ( ) health center
( ) Barangay Health Worker ( ) others, specify _____________________

6. Immunization Status ( EPI= 0-12 months)

AMV/ ROTA MMR STATUS

BCG PENTA OPV Hepa B VIRUS
Name Birthday MEASLES

1 2 3 1 2 3 1 2 3 1 2 3

STATUS: FIC, Ongoing, Dropped Out, No Immunization

7. Nutritional Status / Operation Timbang ( 0-72 months )

Age in Weight in Date Height BMI Interpretation

Name Birthday Status
mos. kg. Weighed ( inch)

8. Maternal Health Nursing: Childbearing Mothers 15 - 49 years old

a. Number of pregnancy: _____________________
b. Number of children born alive _______________
c. Number of infant born dead_________________
d. Number of abortion _______________________
e. Weight ( if pregnant) _________ kgs

9. Prenatal Check-up or consultation ( ) Yes Where: _______________ ( ) No

10. Tetanus Toxoid Immunization

Name LMP EDC AOG TT1 TT2 TT3 TT4 TT5 Status

STATUS: Safe (with ongoing prenatal check-up and TT Immunization), Danger (either NO prenatal
check-up or TT Immunization)

11. Family Planning

Not Length used

Name FP Acceptor Method ( latest)
Acceptor

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 12. Reasons for Family Planning
__________________________
__________________________

13. Have you had adequate

a. Rest and sleep? ( ) Yes ( ) No
b. Exercise ( ) Yes ( ) No
c. Relaxation and stress management techniques? ( ) Yes ( ) No

F. COMMUNITY AWARENESS

1. Are you aware of existing organizations in the community? ( ) Yes ( ) No

2. Name all organization/s you know.
a. .
b. .
c. .
3. Are you a member of any of these organizations? ( ) Yes ( ) No
4. Are you aware of its activities? ( ) Yes ( ) No
5. How are you involved in its activities and projects?
( ) attend meetings ( ) give donations
( ) planning ( ) evaluation
( ) implementation ( ) others, specify _______________

6. Name 10 formal and non-formal leaders of the community whom you think can lead people.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Interviewed by:

_________________________________

Name of Student

Noted by:

_________________________________

CHN Instructor

Skill Checklists for NEUST College of Nursing:

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