FAMILY ASSESSMENT GUIDE

Family Name: Antonio________________ Address: Deca Homes, Tacunan, Davao City

I. DEMOGRAPHIC DATA
Household Number:0011000________ Barangay House No.: __N/A_________
II. FAMILY DATA
Length of Residency: ____Four (4) years______________________________
Place of Origin: Husband-North Cotabato
Wife- Bukidnon________
Family Size: __Five (5) __________________________________________
Religion: Husband- __Roman Catholic___________________
Wife- _____Roman Catholic___________________________

FAMILY MEMBER’S CHART

FAMILY AGE SEX CIVIL POSITION RELATIONSHIP EDUCATIONAL OCCUPATION

MEMBERS STATUS IN THE TO THE ATTAINMENT
FAMILY FAMILY HEAD
1. Ambong 36 M M Head - Elementary Tricycle Driver
Level
2. Razyl 33 F M Mother Wife Elementary Selling fish
Level
3. Rose 12 F S Daughter Eldest Child Elementary Student
Level
4. Prince 6 M S Son Second Child Grade 1 Student

5. Noberto 4 M S Son Young Child Nursery Student

III. FAMILY CHARACTERISTICS

Type of family Structures
A. Extended ____________ D. Nuclear _/__________
B. Matriarchal ___________ E. Patriarchal _/________
C. Dominant Family Member ____________

GENERAL FAMILY RELATIONSHIP/DYNAMICS

 CRITERIA STATUS ADDITIONAL
INFORMATION
OBSERVE CONFLICTS (-) Wife beating, frequent
BETWEEN FAMILY quarreling
MEMBERS.
CHARACTERS OF (-) Talks disrecpectly
COMMUNICATION.
INTERACTION PATTERNS (+) Hurling insults and
AMONG MEMBERS. swearing noted when
talking to each other

FAMILY DIETARY HABITS

What did you eat yesterday? (24 hours’ dietary recall)
Breakfast: __(Skip)___________________________________________
Lunch: __Rice, Adobong Sitaw__________________________________
Supper: _Rice, Inihaw na isda, saging_____________________________

MONTHLY FAMILY INCOME

Husband: __/________________________________________________
Wife: _____/_________________________________________________
Others: ____________________________________________________

MONTHLY FAMILY INCOME SOURCE

TOTAL (CHECK BRACKET)
Below ₱5,000. 00 __/___ Above ₱20,000.00- ₱30,000.00 _____
Above ₱5,000- ₱10,000.00 _____ Above ₱30,000.00-₱40,000.00 _____
Above ₱10,000.00-₱15,000.00_____ Above ₱40,000.00-₱50,000.00 ______
Above ₱15,000.00-₱20,000.00_____ More than ₱50,000.00 ______

FAMILY HEALTH STATUS/HEALTH HISTORY

Father: Normal
Mother: Cough and cold
Children: Rose: Normal
Prince: scabies
 Noberto: malnourish, cough and cold

FELT FAMILY NEEDS (Identify and rank according to priority)

1. Dagdag kilo 5. Gamot sa ubo at sipon
2. Wastong tapunan ng basura 6. Gamot sa galis
3. Kawalan ng tubig 7. Kawalan ng sapat at masustansyang pagkain
4. Kalinisan sa pagkain 8. Kakulanangan sa pinansiyal

IV. HOME AND ENVIRONMENT

A. Is your lot owned? ____ Yes _/__ No
B. Is your house owned? ____ Yes _/__ No
C. Type of Housing Materials
_/_ Wood ___ Concrete ____ Mixed
___ Makeshift ___ Others, specify _____________________
D. Is the living space adequate ____ Yes _/_ No
E. What are the appliances owned by the family?
Refrigerator, Television, Washing Machine, Rice cooker, Heater

F. Type of Garbage Disposal

_/_ Collected ___Waste Segregation ____Feeding to Animals
_/_ Open Dumping ___Burning ____Burying
___ Throw in the river/sewer _____Others, specify _____________
G. Type of Waste Disposal
___ Flush _/__Wrap and Throw ____ Water-sealed
___ Pit Privy ____Others, specify _________________________
H. Types of Drainage system ____ Open _/_ Closed
I. Type of Water Supply
___ Owned ____ Bought __/_Shared
___Others, specify _______________________
J. Drinking Water Storage
 __ Refrigerated __/_Uncovered ___ Covered
K. Containers Used
___Plastic Pitchers ____ Jars, Clay Pots
__/_Bottles ____ Others, specify _____________
L. Food Storage/Cooking Facilities
___ Covered _/__ Uncovered ____Stove
___ Refrigerator ___ Cabinet ____ Pots/pans etc.
M. Common household pests found at home
Cockroaches, mice, ants, and mosquitoes

N. Are there breeding sites of insects, rodents, etc. present? /_ Yes __No
O. Pets/animals kept in the yard/home
Dog, ducks, chicken

P. Are there accident hazards present? _/_ Yes ___ No

V. HEALTH AND HEALTH PRACTICES

A. Common illness encountered for the last 6 months and the treatment applied.
Scabies- dahoon ng bayabas Cough/Cold- Oregano, Lagundi
B. Whom do you consult for health-related problems?
_/_ Manghihilot _/__ Albularyo
___ Midwife ____ Nurse
___ Doctor _/__ Health Center
___ Barangay Health Worker ____ Others, specify _____________
C. For problems other than health, whom do you consult?
_/_ Family Members _/__ Relatives
___ Friends ____ Barangay Officials
___ Priest ____ Others, specify ______________
D. Immunization status of family members.
All children are vaccinated.
 E. Have you had adequate
1. Rest and Sleep? _/_ Yes __ No
2. Exercise? ___ Yes _/_ No
3. Relaxation Activities? ___ Yes _/_ No
4. Stress Management Activities? ___ Yes _/_ No

VI. ENVIRONMENT

1. Kind of Neighborhood. Subdivision

2. Social and Health Facilities Barangay Center, Mintal Gym
available.
3. Communication & Transportation Tricycle
facilities.

VII. AWARENESS OF COMMUNITY ORGANIZATION

A. Are you aware of existing organization in the community? ___ Yes _/_No
B. Name all the organization/s you know.
N/A
C. Are you a member of any of these organization? ___ Yes _/_ No
D. Are you aware of its activities and project? ___ Yes _/__No
E. How are you involved in its activities?
___ Attend Meetings ___ Give Donations
___ Planning ___ Evaluation
___ Implementation _/_ Others, specify __not involved_____
F. Name 5 formal and non-formal leaders of the community whom you think can lead the
people.
1. Ate Lena (Manghihilot)
2. Mrs. Sineneng (Purok Leader)
3. Bobby
4. Kapitan
5. Kapitana