FAMILY HEALTH ASSESSMENT GUIDE 1

I. GENERAL DATA
Family Name : EDICTO
Name of Barangay : MARAY-MARAY
Name of Purok : P-2
Household No :1

II. FAMILY DATA

Length of residency : 35 years
Place of origin : Don Carlos Bukidnon
Family size : 6 members
Religion : Born again Christian
Husband : Isaias Edicto
Wife : Maria Liza edicto
FAMILY MEMBER’S CHART
Marital Highes
Name Relation Se Date of Birth Ag Status t Occupation
to Head x Month Da Year e Educati Type Place
y on of
work
Isaias Father College Self
Edicto Level( s empl
Marrie
M April 2 1971 49 topped oyed Don Carlos
d
3rd (labor
year) er)
Maria Mother College Self-
Liza Level empl
Marrie
Edicto F December 27 1975 45 (stoppe oyed Don Carlos
d
d until (labor
3rd year) er)
Ian Mar Son College Self
Edicto (stoppe empl
Marrie
M Decemver 2O 1993 26 d until oyed Don Carlos
d
3nd (labor
year ) er)
Ike John Son Call
Edicto Marrie College cente
M April 9 1994 25 CDO
d Level r
agent
Excil Son M October 23 1996 3rd
John 24 Single year N/A N/A
Edicto college
Illaizah Daughter F January 24 20 2nd
Edicto 20 Single year N/A N/A
college

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 Good Conflicts in the family seldom
occur
Characteristics of communication Good Members are able to express
their opinions and thoughts
within the family
Interaction patterns among members Good Members are able to see and
interact with one another in a
day to day basis

3. Monthly Family Income Source

Husband: ____________ Wife: ______________ Others:__________
( ) P 3, 000.00 and below________( __________
( ) P 4, 000.00 – P10, 000.00________________
( ) P 11, 000.00 – P15, 000.00 ________
4. Family member heading on decision making? _________________________
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: 5
D. Furniture: ( ) None (/ ) Limited ( ) Adequate
E. Home appliances present: Television (2), Refrigerator, exhaust fan, iron,
speakers
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: water pump
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 _________
E. Distance of comfort room from the water source: 4-6 meters
4. Waste Management
A. Garbage
1. Type of garbage disposal
( /) collected : monthly ( ) 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: separation of non-biodegradable to biodegradable
waste
3. Do you recycle garbage? ( /) yes ( ) no
If yes, specify how: peelings are used as fertilizers
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: Presence open containers outside the house used for collecting
rain water
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: no breeding control
method applied
D. Pets/animals kept in the yard/home: dog, cat,
6. Plants/Vegetation
A. Plants in the surroundings
(/ ) Vegetable ( /) Herbal ( / ) Ornamental
B. List kinds of vegetable plant found in the surroundings
C. No vegetable plants. Catus, succulents, and snake plants present
D. Information on the herbal plants approved by DOH? (/ ) Yes ()
No
If yes, please fill up the table below:

HERBAL PLANT INDICATION METHOD OF USE

N/A N/A N/A
N/A N/A N/A
V. HEALTH AND HEALTH PRACTICES

1. Common illnesses encountered for the last 6 months and the treatment applied.
NAME COMMON ILLNESS TREATMENT
Isaias Edicto Common cold Water therapy, intake of oral
meds, ‘tuob’
Maria Liza Edicto Common cold Water therapy, intake of oral
meds, ‘tuob’
Excil John Edicto Common cold Water therapy, intake of oral
meds, ‘tuob’
Illaizah Edicto Common cold Water therapy, intake of oral
meds, ‘tuob’
2. Whom do you consult for health-related problems?
(/ ) hilot ( ) midwife (/ ) doctor ( ) albularyo
( ) barangay health worker ( ) rural health center ( ) nurse ( ) others
Delivery system: ( /) home (/ ) hospital ( ) clinic ( )others
Availability/Utilization of health services: (/ ) Yes ()
No,Why_____________
3. Health personnel feedback ( / ) Friendly ( ) Unfriendly
4. 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
NAME OF CHILD AGE OR NO IMMUNIZATION
N/A N/A N/A
N/A N/A N/A
D. Place where the child obtains immunization inoculation?
( ) Barangay Health Center ( ) Clinic ( ) Hospital (/ ) Others: N/A family has no
child member aging from 0-2 years
E. Do you know the diseases a child would acquire if not immunized?(/ )Yes ( ) No
If yes, specify the disease Tetanus, polio, heap B
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 (/) Not
applicable

5. NUTRITION

A. Children 0-5 years

AGE IN DATE NUTRITION
NAME OF CHILD MONTHS WEIGHT HEIGH OF STATUS
T BIRTH
N/A N/A N/A N/A N/A N/A
N/A N/A N/A N/A N/A N/A
N/A N/A N/A N/A N/A N/A
B. Food given to children 0-2 years:
( ) breastmilk ( ) milk formula ( ) mixed feeding – (BF +) ( /) Others,
specify: N/A
C. Type of infant formula used: N/A
D. How they clean their feeding bottle? N/A
E. What supplementary foods do they give to the child? N/A
F. Does Vitamin A give to children of 12 – 59 mos.? ( ) Yes ( ) No
(/) Not applicable, no family member aging 12-59 months
If yes, when was the last vitamin given? Month’s N/A Year N/A

6. PREGNANCY

LAST NUMBER
NAME OF MENSTRUAL AGE OF TETANUS NUMBER OF OF
PREGNANT PERIOD PREGNANCY TOXOID PREGNANCY PRENATAL
WOMAN VISITS
N/A N/A N/A N/A N/A N/A
N/A N/A N/A N/A N/A N/A
G. Did you experience miscarriage? ( ) Yes ( ) No (/) Not
applicable, no pregnant woman in the family
A.
If yes, specify the reason?
__________________________________________________
B. Where do you go for prenatal? ( ) Health Center ( ) Therapist ( ) Doctor
( ) Others, specify: N/A

7. 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) N/A
D. How long have you been using the family planning method? N/A
E. Was there any significant effect you felt as you used this kind of method? ( )
Yes ( ) No (/) Not applicable
If yes, please specify below:
_________________________
_________________________
8. 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)
9. Felt Family Needs (Identify and rank according to priority

FAMILY NEEDS PRIORITY

1. Nursing education about the importance of maintaining Second
individual health and hygiene
2. Health teaching on the importance of having adequate Fourth
sleep
3. Nursing education on the benefits of engaging on Third
physical and recreational activities
4. Nursing education about the importance of maintaining a First
balanced diet
VI. ENVIRONMENT
1. Possible breeding sites of vectors of Conduct health teaching about the risks
diseases are present (stagnant of stagnant water in houses
water)
2. Inadequate lighting Teach the family about the risks of
unwanted incidents due to light hazard
VII. AWARENESS OF COMMUNITY ORGANIZATION
A. Are you aware of existing organizations in the community? (/ ) yes ( ) nName all
the organization/s you know.
B. Malaybalay City Health Office, Bukidnon Provincial Medical Center, Philippine
Red Cross – Bukidnon Chapter

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.Judy Palmada
1. Pantaleon Paradero
2. Vilma Ontanillas
4.Emma Pasulot
5.Allan Remido
VIII. HEALTH INSURANCE
A. Information about Health Insurance (/ ) Yes ( ) No
If yes, where the information obtained
(/ ) Government agency Name: PHILHEALTH, DOH
( ) Private agency Name: _______________________________
(/ ) 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: