CHINESE GENERAL HOSPITAL COLLEGES

COLLEGE OF NURSING
FAMILY ASSESSMENT TOOL

FAMILY NAME ___________________________ Head of the Family ____________________

Address: _____________________________________________________________________________________

I. DEMOGRAPHIC DATA
Household Number (number of families in the house) ____________________

II. FAMILY DATA

Length of residency ____________________
Place of Origin: Husband ____________________
Wife ____________________
Family Size ____________________
Religion: Husband ____________________
Wife ____________________

Family Member’s Chart

RELATION TO
CIVIL HEAD OF THE EDUCATIONAL
NAME AGE SEX STATUS FAMILY ATTAINMENT OCCUPATION
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Members of the family not living in household/Occupation

1.
2.
3.

Family Characteristics
Type of Family Structure
A. Extended _____ C. Nuclear ____
B. Matriarchal ____ D. Patriarchal__

Dominant Family Member ___________________________

Relationship of members
1. Husband and Wife _________________________________________
2. Father and Children ________________________________________
3. Mother and children ________________________________________
4. Children to children ________________________________________

III. SOCIOECONOMIC AND CULTURAL FACTOR

EDUCATIONAL RELIGIOUS SOURCES OF

NAME LEVEL AFFILIATION INCOME INCOME
1.
2.
3.
4.
5.

Total monthly family income source: ( ) below 5,000 pesos ( ) above 5,000 – 10,000 ( ) above 10,000 – 15,000
( ) above 15,000 – 20,000 ( ) above 20,000 – 30,000 ( ) above 30,000 – 40,000 ( ) above 40,000

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IV. ENVIRONMENTAL FACTORS
1. Housing:
a. Ownership: ( ) owned ( ) rented
b. Type: ( ) light ( ) mixed ( ) strong (concrete)
c. Number of rooms used for sleeping: __________________________
d. Lighting facilities: ( ) electricity ( ) kerosene ( ) others: specify ___________________
e. General sanitary condition: ___________________________________________________________

2. Drinking water supply

a. Source ( ) private ( ) public
b. Storage ( ) None (direct from faucet or pipeline) ( ) plastic pitchers ( ) jars, clay pots
( ) bottles ( ) others, specify ___________________

3. Kitchen/ Food storage

a. Cooking facility ( ) electric stove ( ) gas stove ( ) firewood/ charcoal
b. Sanitary condition: _______________________________________________________________________
c. Food storage( ) covered ( ) refrigerated ( ) placed in cabinet ( ) others, specify ___________
d. Drainage facility ( ) open ( ) closed/ blind ( ) none

4. Waste disposal
a. Refuse and garbage method of disposal: ( ) garbage collection ( ) open burning ( ) composting
( ) open dumping ( ) burial in pit ( ) feeding to animals ( ) others/specify _______________

b. Toilet Facilities
Type: ( ) pit privy ( ) water sealed ( ) flush
( ) flying saucer/wrap and throw ( ) others, specify _________________________
Location: ( ) inside the house ( ) outside the house
Sanitary condition: _____________________________________________________________________

5. Domestic animals
Kind Number Where Kept

6. The community in general (SPECIFY EACH COMMUNITY)

a. General sanitary condition: __________________________________________________________________
b. Type of neighborhood ( ) Residential ( ) Industrial ( ) Rural ( ) Urban
c. Housing congestion: ( ) Yes ( ) No
d. Presence of breeding sites of vectors of diseases: ( ) Yes ( ) No
e. Presence of accident hazards ( ) Yes ( ) No
f. Accessibility of health facilities ( ) Yes ( ) No
g. Accessibility of Churches ( ) Yes ( ) No
List of Churches
1.
2.
3.
h. Accessibility of schools ( ) Yes ( ) No
List of Schools
1.
2.
3.
i. Availability Public transportation ( ) Yes ( ) No

V. HEALTH AND MEDICAL SURVEY

A. Present Health Status of each members of the family

B. Past significant illnesses and accidents of each member (for the past 2 years)
Name of Family Member Past Illness/Accidents
1.
2.
3.
4.
5.

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 C. Immunization Status of each member (infants to children 5 years old)
Name of family member Type/Kind of Immunization Immunization Status
1.
2.
3.
4.
5.

D. Health Care Resources Utilization

1. Whom do you consult for health related problems?
( ) doctor ( ) nurse ( ) midwife ( ) barangay health worker
( ) manghihilot ( ) albularyo ( ) others, specify __________________________
2. For problems other than health, whom do you consult?
( ) family members ( ) friends ( ) relatives ( ) barangay officials
( ) priest ( ) others, specify
3. 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

VI. Awareness of Community Organization

A. Are you aware of existing organizations in the community?
( ) Yes ( ) No
B. Name all the organizations/s you know.
( ) Yes ( ) No
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 ( ) give donations ( ) planning ( ) implementation
( ) evaluation ( ) others, specify _______________________________________________

F. Name 5 formal and nonformal leaders of the community whom you think can lead the people.
1.
2.
3.
4.
5.

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