COLLEGE OF NURSING

CARLATAN, SAN FERNANDO CITY, LA UNION

FAMILY ASSESSMENT GUIDE

COMMUNITY NEEDS ASSESSMENT /MINIMUM BASIC NEEDS (MBN) FOMR
Date: Febuary 07 , 2022

Family Name: Galang, Darapidap(Barangay)

I. Demographic Data
Household Number: ___N/A_ Barangay House Number: __N/A___
II. FAMILY DATA
Length of Residency: 20 years Place of origin: Bangued, Abra
Family Size:__4__Religion: Husband:Roman Catholic wife:Roman Catholic

FAMILY MEMBER’S CHART

FAMILY MEMBERS A SEX CIVIL POSITION IN RELATIONSHI OCCUPATION

STATU THE FAMILY P TO THE
G EDUCATIONAL

S FAMILY ATTAINMENT
E HEAD
1.GALANG, Noel Gregory G. 53 M M Father Husband College Farmer
Graduate
2.GALANG, Ma. Teresa S. 50 F M Mother Wife Undergrad Store
owner
3.GALANG, Jane Mariel S. 23 F S Daughter Daughter College Self-
Graduate employed
4.`GALANG, Janielle Marie 12 F S Daughter Daughter Grade Student
School

Type of Family Structure

A. Extended: ____ B. Matriarchal: _____ C. Dominant Family Member: ___
D. Nuclear: / E. Patriarchal: _____

General Family Relationship/Dynamics

CRITERIA STATUS ADDITIONAL
INFORMATION
Observable conflicts between family Financial Problem Both parents argue
members about money
Characteristics of communication Well-versed Can engage
conversation
Interaction patterns among members Close bonding Sometimes
misunderstanding but
still manageable

Family Dietary Habits

What did you eat yesterday? (24 hours dietary recall)
Breakfast: Black Coffee, Rice, Egg
Lunch: Rice, Meat, Vegetables
Dinner/Supper: skipped
Monthly Family Income Source
Husband: ___________________________ Wife: ______________________________
Others: ________________________________________________________________

below Ph 5,000_____ above PhP 20,000- 30,000 __________

above Ph 5,000-10,000____ above PhP 30,000- 40,000___________
above Ph 10,000- 15,000___ above Ph 40,000- 50000 ____________
above Ph 15,000-20,000__/__ above Ph 50,000

FAMILY HEALTH STATUS/HEALTH HISTORY

Father: Hypertension, Headache, Coughs
Mother: Colds and Coughs
Children/s:Headache,Coughs and colds.

FELT FAMILY NEEDS (Identify and rank according to priority)

1. Stable Job .
2. Money
3. Foods
III. 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? TV,E FAN, REFRIGERATORS
CELLPHONE.
F. Type of Garbage Disposal
_____/_____Collected __________burning
__________Waste segregation __________burying
__________ feeding animals __________throw in the river
__________open dumping __________ others, specify _____
G. Type of waste Disposal
_____/_____Flush __________ water-sealed (private)
__________wrap and throw __________ pit-privy
__________dig and bury _________water-sealed (communal)

Others,specify_____________________________________________________
H. Types of Drainage System __________Open ______/______ Closed
I. Source of water ___________owned _______/________bought __________shared
Others, specify_________________________________________________________
J. Drinking water storage
_____/______refrigerated _____/____Covered Uncovered: ____________
K. Container used
______/______Plastic pitchers _____________jars /clay pots
______/______bottles _____________others,specify
L. Food Storage/ Cooking facilities
_____/______Covered ______________Uncovered _____/______Stove
_____/______Refrigerator ______________Cabinet ______/____Pots/pans
M. Common Household pests found at home
1.Cockroaches
N. Are there breeding sites of insects, rodents present? YES__________NO____/____
 O. Pet/ Animals kept in the home/Yard: Dogs and cats
P. Are there hazards present? YES ________________ NO____________/____________

IV. HEALTH and HEALTH PRACTICES

A. Common illnesses encountered for the last 6 months and treatment applied
______/______ diarrhea ___/____ colds _______/______cough
____________influenza_______stomach pains_____/__headache
____________toothache__/ ____Hypertension________Diabetes
____________gastritis ________ __________________others, specify
B. Whom do you consult for health-related problems?
___________” Manghihilot “ __________midwife
_____/______Doctor __________BHW
___________quack doctor/ albularyo __________Clinic
___________self-medication 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:complete
E. Have you had adequate?
_____1. Rest YES__/_ NO______
_____2. Exercises YES__/__ NO______
_____3. Relaxation Activities YES__/__ NO______
_____4. Stress management YES__/__ NO______

V. KIND OF NEIGHBOORHOOD
1. Kind of Neighborhood
2. Social and Health facilities available Barangay Hall
3. Communication and transportation Cellphone and Tricycle

V. AWARENESS OF COMMUNITY ORGANIZATION

A. Are you aware of the existing organizations in the community? YES___/___ NO_________
B. Name all the organizations you know? Sangguniang Kabataan
C. Are you member of these organizations? YES____/___ NO_____________
D. Are you aware of its activities and projects? YES__/___ NO_____________
E. How are you involved in its activities?
____/___1. Attend meeting _______4. Give donations
____/___2. Planning _______5. Evaluation
____/___3. Implementation others, specify_____________________
F. Name five (5) formal and non-formal leaders of the community whom you think can lead the
people?
POSITION
1. Singson, Ericson Incubment City Mayor
2. Galang, Engr, Florante City Engineer
3. Bugasto, Ricardo Brangay Captain
4.Caabay, Joffrey Barangay SK Chairman
5.Soliven, Rowel Barangay SK Secretary

Interviewer: GALANG, MARK JASON S.

Student Nurse II Section: BSN-II LEWIN
Clinical Instructor: Mrs. Cherry Catli