FAMILY CASE STUDY INTERVIEW QUESTIONS

Patient’s Profile

Name:

Age:

Birthday:

Birth Address:

Present Address:

Nationality:

Religion:

Languages Spoken:

Position in the Family:

Civil Status:

I. Family Structure, Characteristic and Dynamics

A. Members of the Family No.

AGE SEX CIVIL STATUS POSITION IN THE RELATION TO THE

FAMILY HEAD OF THE
FAMILY
Head:

Members:

B. Family structure

1. What type of family? Nuclear / extended?

2. Who do you live with?

3. Since when did you live here?

C. Dominant family members (decision making with health matters)

1. Who decides for the family when it comes to health matters?

D. General family relationship

Objective:
1. Usual activities of every family member everyday?

Subjective:
 1. Are you close with one another?
2. Who are you closest with?

II. Socio-economic and Cultural Characteristics

A. Educational Attainment
Name Educational Attainment

B. Income

Name Occupation Monthly Income

TOTAL:
Elaborate occupation & income. Location of work, etc.

C. Expenses
1. Budget?
2. Electric bill?
3. House maintenance bills?
4. Leisure bills?
5. Allowance and tuitions?

D. Ethnic background and Religion

E. Relationship of the family to larger community

1. Is the family active members of the community?
2. Are they close with the neighbors?
3. Part of any community organizations?
4. Are you willing to help other people in the community?

III. Home and Environment

1. Type of house?
2. Made of what?
3. When was it constructed?
4. Problems with the house? Broken windows, slippery
stairs? Too dark?
5. Do you feel safe at home?
6. How many rooms in the house?
7. How many bathrooms?
8. How many outlets? Any problems with electric outlets?
9. Means of cooking?
10. Waste segregation?
11. How do you manage wastes? Burning, dumping or there
are garbage trucks that collect it?
12. Any family vehicle?
13. Pets?
14. Problems with pets?
15. Any problem with the neighbor’s pets, e.g. smelly odor in
the backyard?
16. Fond of plants and trees?

IV. Health Status of Each Family Member

A. Nutrition and Medication

 1. How many times do you eat in a day?
2. Usual food routines?
3. Who cooks?
4. Who buys grocery?
5. Time of meals?
6. How many glasses of water consumed by each member?
7. Fond of alcohol? Any family member?
8. Fond of acidic beverage? Any family member? How many or how often do they drink?
9. Vitamins or supplements taken?
10. Maintenance meds?
B. Health Status
1. Any allergy of any member?
2. Any past illnesses?
3. When were you diagnosed with peptic ulcer?
4. How often do you feel symptoms? What symptoms?
5. What aggravates symptoms?
6. Any severe health problems of any member of the family?

V. Values, Beliefs, Practices on Health Promotion, Maintenance and Disease Preventions

A. Immunization

1. Complete vax since childhood? Every fam member:

2. COVID vax? What vax? Booster?

3. Recent vax?

4. Side effects from vax?

B. Health and Lifestyle practices

1. Any problems in performing daily tasks?
2. Feel weak whenever performing tasks?
3. Tips on keeping healthy?
4. Adequate sleep or rest?
5. Eating junk foods or drinking soft drinks?
6. Medical check-ups? How often?
7. Importance of health?

VI. Adequacy of:

A. Rest and Sleep

1. Usual sleep time of everyone?
2. Usual waking up time?
3. Do you feel well rested after sleeping?
4. Afternoon naps?
5. Sleeping pills?
6. What hinders your sleep?

B. Activity Level and Exercise

1. Do you all exercise?
2. How often?
3. Are household chores your exercise?
4. Do you have any problems with household chores?
5. Are the chores equally divided?
6. Is everyone physically active?
C. Use of Protective Measures
1. Use of mosquito net or sprays?
2. Do you clean the surroundings?
3. Any sewage water problems?
4. COVID 19 precautions?

D. Relaxation and Other Stress Management

 1. Hobbies?
2. Any relaxation measures when stressed?
3. Does the family watch TV?
4. Screen time on phone?
5. What makes you calm down?

E. Use of promotive-preventive health service

1. Able to access health care services in the barangay?
2. Attending all seminars or assembly about health in the barangay?
3. Any health concerns?
4. Any close healthcare worker whom you can ask about certain health problems?

VII. Family Assessment Tools

A. Family Apgar

Almost Some of the Hardly Ever

always time

A I am satisfied that I can turn my family for help when

something is troubling me

P I am satisfied with the way my family talks on things with

me and shares problems with me

G I am satisfied that my family accepts and supports my

wishes to take on new activities or directions

A I am satisfied with the way my family expresses affection

and responds to emotion such as anger, sorrow and love

R I am satisfied with the way my family and I share time

together

PART I

PART 2

WHO LIVES IN YOUR HOME? HOW DO YOU GET ALONG?

Name Relationship Age Sex Well Fairly Poor

Husband

Wife (Client)

Eldest Child

Middle Child

Youngest Child

IF YOU DON’T LIVE WITH YOUR FAMILY. LIST THE PERSONS TO HOW DO YOU GET ALONG?
WHOM YOU TURN TO FOR HELP.
 SCORING: Total:

Almost always – 2 8-10 – highly functional

Some of the time – 1 4-7 – moderately dysfunctional

Hardly ever – 0 0-3 – severely dysfunctional

B. Genogram

CLIENT

MOTHER FATHER
SIBLINGS

HUSBAND OF CLIENT

MOTHER FATHER
SIBLINGS

C. Ecomap

Work

- Who have hectic scheds?

Religion

- Does everyone have strong relationship with God?

- Who usually goes to mass?

School

- Pressured/anxious?
- Chill?

Friends

- Get along with friends

- Many friends or none?

Recreational Activities

- What do you usually do?

- Playing cards, reading, videoke, biking?