PHINMA-UNIVERSITY OF PANGASINAN

COLLEGE OF HEALTH SCIENCES

Nursing Department
S.Y 2021-2022

FAMILY HEALTH ASSESSMENT FORM

GROUP 3

LEADER: Alonzo, Jan Mary Cielo T.

MEMBERS:
Fernando, Iraa Sheane
Mendoza, Angelica
Pasamon, Krzyzandra Marie
Umayam, Vivian
 FAMILY HEALTH ASSESSMENT FORM

Family Surname: Fernando

House No.: 551
Street: Tagudin St.
Barangay: Nancamaliran West District: 5
Municipality: Urdaneta City
Contact Number: 09154530834
Source (s) of Information: Mary Ann G. Fernando
Data Gathered by: Group 3 members
Date: January 19, 2022

Household Members
NAME AGE RELATIONSHIP TO THE HEAD OF THE
HOUSEHOLD
Fernando, Dionisio David 55 Head of the Family
Fernando, Mary Ann Gatchalian 53 Husband
Fernando, Darnell Jonas Gatchalian 26 Father
Fernando, Iraa Sheane Gatchalian 19 Father

Insert Genogram, Family tree (indicating health problems of the individual members), and / or ecomap
in this section.

FAMILY
CHARACTERISTICS

Family members living outside the household: None

● Name, age, and relationship to the head of the household

NONE

● Location of the family member(s)

NONE

● Frequency and duration of contact

NONE

● Means of communication (Snail mail, social media, e-mail)

NONE

***

Family mobility

● Length of time at current address

27 years

● Address of previous residence(s)

None

● Frequency of geographic moves

None

***
Family Dynamics

● Emotional Bonding of Family Members

During meals, going to the mall and shopping sometimes.

● Distribution of authority and power ( Patriarchal/Matriarchal)

Even authority and power between the Patriarchal and Matriarchal

● Degree of individual autonomy (High/Low)

 Low degree of autonomy, usually the decision comes from the Patriarchal and seldom from the other
members of the family.

● How members communicate (open/close)

It’s an open type of communications.

● How decisions are made

Decisions are made first between the husband and wife after that, we ask our son and daughter’s
thought.

● How problems are solved

Proper communication with the whole family.

● How conflict is handled

Proper communication and thorough advise.

● Division of labour (household chores done who among the members of the family)

Alternate but mostly, as mother I do the household chores.

***

SOCIO-ECONOMIC AND CULTURAL CHARACTERISTICS

Family Social Interaction

● Language(s) or dialect(s) spoken

Ilocano, Tagalog and sometimes English.

● Literacy (Level of literacy; ability to read and write in language(s)

Can read and write in Ilocano, Taglog and English.

● Degree of social network with friends, neighbours , and other relatives ( strong or poor bonding)

Strong bonding

● Network with religious organizations (mass/church involvement activities)

Attending mass on Sundays, but as we are in the midst of pandemic now mostly through online mass.

● Network with social organizations (active or inactive participants in the program of their place)

Inactive
Cultural influences: values, attitude, and beliefs about:

● Spirituality (Adherence to religion)

 Roman Catholic

● Rituals (holidays and celebrations)

Holy week observance, Christmas and New Year Celebration.

● Dietary habits (High-fat, High-Na diet, frequency of meals a day)

3 meals a day with snacks in the morning and afternoon during weekend with family.

● Health (One or two member of the family has co-morbidities)

Matriarchal of the family has hypertension with daily maintenance.
● Folk Diseases (Usog, Kulam, Barang)

Luckily the family hasn’t experience any of those, there are just some rumors circulating.

● Traditional Healers (Hilot or tawas)

Hilot, but it’s just when our son and daughter were still below 5 years old.

Month Family Income source

● Monthly Income (estimated income ranges in Peso)

30,000

***

FAMILY ENVIRONMENT

Family Residence

● Adequacy of size (Small or Big)

Medium size

● Structural safety

Concrete

● Water Sanitation

Prime water source and mineral water.

● Food Preparation and storage

Washing hands properly, cooking the food thoroughly and storing leftovers in the refrigerators so
that it will not easily get contaminated.
● Sewage ( Sewage system is present or not)

It is present.

● Garbage disposal ( Frequency of garbage collection by the LGU, include the day of collection)

No garbage trucks in the barangay, we bring the garbage in the market place where there is garbage
container.

● Excreta Disposal ( overhung latrine, cat-hole, sanitary pit trivy, water-sealed latrine, pail system)

Water-sealed latrine

● Pest and Vermin Control

None

● Pets and other animals (Within home or streets)

We have 6 cats at home.

Family Neighbourhood

● Location (e.g., urban or rural, subdivision, slum area)

Urban area

● Type (e.g., residential, semi commercial)

Residential

● Safety

Traffic patterns – There are traffic signs present in the community.

Lighting- (e.g. adequate) - There is adequate traffic light and street lights.
Security (police or private) - There are barangay police or tanods roaming day and night.

● Population density (uniform/crowding)

Uniform

● Sources of Pollution

Air- None
Water – None
Soil – None
Noise- None
__________________________________________________________________________________________
***

FAMILY HEALTH AND HEALTH BEHAVIOUR

● Activities of Daily Living (how many family spends a typical day)

Alternate on household chores.

● Health history (Pregnancy, illness, death within the past 5 years/ health attendance)

Maternal member; hypertension for 20 years

● Self-care (health promotion and disease prevention

Proper exercise, fruits and vegetables rich in vitamin C.

● Risk behaviours

Other members have vices like smoking and drinking alcohol.

● Health Status (Problems and priorities)

Hypertensive member and alcoholic members

● Home remedies

Consume over the counter medicines for cough, cold, headache and Tepid sponge bath for fever.

● Health Care resources

City Health offices and Urdaneta City General Hospital

● Health Workers ( Health Professional they seek)

Physicians and Nurses

● Health agencies (name of RHU, hospital)

Urdaneta City Health Office and Urdaneta City General Hospital

***
Adapted from Nies and McEwen, 2011. Community/public health nursing, 5th edn. Saunders