WESLEYAN UNIVERSITY-PHILIPPINES “omUnck . ‘COMMUNITY HEALTH NURSING | \ | FAMILY ASSESSMENT GUIDE any names Male, nares TEEN weer tp TT FARLY DATA 8 Lengthotresidency 34 Yeas urban pce tog le pt gh Tage CC reves Te [oe] oe [se | ma |e | [Fed poles Cade CT Te Pty Tom Prt Marat coite | > _| ih vl Dn [tain Merling Cactim Howell p £ | Dealt | dete LRki TM Nl 93 TP | fad Teed. font | Now TTT Ps "TYPE OF FAMILY STRUCTURE (ek the appropriate box) Tsar iene “Matrlarcha aca Dinan ay aber (iia rae peat ype of family) Sal parent ony Chess any Sep fay rendu only \ ‘STATUS negative] postive 1, Observable confcs between tamly menos [7 "2 Charades of cormunzaton "3_Ineracton pater among mentor Pa agp bay wie apa Hi | a a i Ti Fay cone RSA TORR BAT Tee PSOHOT Tae A= TT enn OY ‘Above 30,000 - 40,000 00Rerw 16 05a Tae an a TA TaeNe tala Gestion elias ag Visit AMLY HEALTH STATUSHEALTH HISTORY Tair Seed! Tie Good 1 Shanon aoe ery (et to) aL ona oer epee 7 pe of waste daposal Ta ‘wrap and vow water ened pipay ethers (ee 0, Braking Water Storage a Rerigorted Covered e_uncovered 13, Cooking faciines Cassa Our ouse owned ce adoquala? “Type of housing material ‘What are the appliances owned by tre famly? “Type of drainage system = Open Do Cosed Ti. Containers Used Tor water ‘eter, day pos &_Ohers (pec) .~Comman pests found at home 7s Fis Bes BH, Temes Tie 5 Type of garbage aposal TE Food storage Tole Waste segregaton = Feeding animal ©Open soning ‘arn bug Tow ino vaTeGwer ars (peo ce of water BuRBTY Zz Ee Gane ‘ous shared aes (ope Covered Uncovered Refigerior Cabinet Others (een) 15. Are there breeding alte for these ests? 3_veS bn cle peel wha pamRe F ‘etslanimals koptin tho Romeljard ‘7. Aro there accident hazards > Present inthe homo? b. a YES 7 BNO 7 NOTE: speciy what hazard é : f 8 CELE Sree acess Common ilinesses suffered in ‘months and the treatment applied Cees TREATMENT APPLIED A oxi Pail © Sididna tpiteh ope ffoupienl 0. Healiané healipractcesconinuedWvcktheappropraté bot wom do you coneu forthe health-related For problems other han health, whom do you consul? problems? 2) Nene a Faas 31M z a) Pres CR made nan a Z 2) “Nurse 2) Brangay oa )__Others (specify) Others (specify) = munization status of amy members Tipe oTimmunnaten Tate Treongita capa EPL der five chien forges 5 yea and er 5 Physteal and montal hal Docs enter offi fy have nadagequts. 7 ay Rest and sop 7 ; b) Exercise s > 2) Relaraton econ “d) Stress management activites ae a ‘@)_Kind of neighborhood By Social and heath recites avaiable ¢) Communication and transportation facies Z_Awareness of community Organization “Are members of the farly aware of exsing ves . ations in the f Fie you aware othe Taiyou teow Fie youa reriber otis By Provide names of erganizatons ee crac | YESNO. YEaMO a Ge acehen Tech tra ba Taran yesWESLEYAN UNIVERSITY PHILIPPINES. COMMUNITY HEALTH NURSING FAMILY ASSESSMENT GUIDE, a TFET 5 2 Longhorn 3 Hinbonds place gn: Bey: Caclbgtongn Cok 2 Herter MO weet Hd FAMILY He Famiy arbors Ne od v Wig TE | lelrabcA Ualmegad | Yu Bean G. Valmradvid | 32 aalionin | Relalorahipto | Edvealonat trefandy_| “famiyhesd_|_Atainnent_|_ Oot" Goat iyive [Tt Gnd fh Daghir_| Dae Goal | Atapfised | Htlabe| ¢ cries TRS aso ed RITERIA ‘STATUS Tepatve | _poslive [i Obsenatie conf between my memes |_| Chan oceTEN TSAO A NG TATONT Fa RR a a Rove TERT FOR 4 iia =m —_ UT 2 Mother Dinter 3 Chitiren Gol ‘+ Ohermanben ake {amity (rico who) FELT FAMILYINEEDS) ii) vil IDENTIFY AND RANK AGE Easne TPE Lie v Te your lot owned? 21s your house owned? “Type of housing material ‘3. Is the living space adequate? 5 Whatare the appliances owned Type of garbage disposal by tho family? a Weed 2 a _caleded Concrete B Waste segregation mated € Feeding o animals é_makesnit é &_Open dumping eaters (pec) e ‘e-_burning t burying | % throwin he rversewer t others pec) 7. pe oT waste dieposal “5 Typo of drainage system 3. Source of water supply a tush Open a Owned B_wrap and row Closed bought Z ‘e_ water sealed shared &_ piri, others pec) e._obvers (spec) "0_ Drinking Water Storage Ti, Containers Used forwater | 12 Food storage storage 3, Refigerated Plasto picher a Covered B__ Covered _Botles Uncovered uncovered ar, day pols __ Refigerator Ors (spect) &_ Cabinet e._ Others (peal) “14, Common pests found at ome Anis Foes. Bed Rais Termes Vice cockroaches 1. Are there breeding sites for these pests? YES NO. Tater epee what pet‘Peainais opin ie omoya_ 4, Ae tere accent bares preeent in the home? Lat 2 YES, = . a @ co ¢ ‘Common nesses suffered De ist 6 months and te beatnent appa COMMON TESS TREATHENT APPLIED, ofa] oy >] = tWESLEYAN UNIVERSITY-PHILIPPIieg, ‘COMMUNITY HEALTH NURSING 1 FAMILY ASSESSMENT GUIDE TEs Household number, hh 1 FART OR ol residency 30 YavF . b Hannes pace eorge: Cuign cy Srigus but Sere <_ Wiles pac olrgn Ke FAMILY MEMBER'S CHART resem Tw [on [ SS [my | ante | mas [ omen Trina Gn a Coal (| EL [Door | Okie [i me [te 2 Tom rie bCavtoin [2H Tm | ty ak Cat red |oatvctin 3 Yuavitw-B. Carrie [53 Te [ty [toe | whe LA Ged” Pic sting © A Treduich cy tastrin Tro Tm [on | teed oat fh Grd _|Pamver. 3 7 = 7 7 EOF FAN RE 1 TNodear 2] Extended ‘3 | Matiarchar Paar ‘5 | Dominant famiy mernber 6] Others: Teale pe a) ‘Single parent family Sooty Grandparent amy T_Otservabe carficls between lay menibers "2 Characters of eonmruntaton ry Aig Henge Le 1,_ HUSBAND (02 2 Wire _[U;po0 ‘Wontiy Fanily Income Amount (CReEK Bracket) cone Ra PODS TOOT Rove 500000 TORO ‘Rove 20000 ~ #00000ave 49,000 - HOOT Apo 10000-1500 Above 15000-20000 Wore than 6000000 Dindetet Ober menber ofthe amy (icate who) IDENTIFY Tae Noes eseerestel cauedaeenune z reared 2s yout house owned? Teta r Type ot hating mati Wood _Conaria med ake ohare (pec Retrgerstor Cabinet Ober peat) ests found athome We: ape what peak 15, Are there broeding ses for these beets? Z 3 ves BONO7a thera cede aaa present in tha home? 8, YES ‘BNO OTE: speci what hazard ‘vestment applied "TREATIIENT APPLIED. ‘Common iinesses wuffered in te last 6 months and COWMON HLNESS ow. Ee "2. Whom do you consult fr the health-related 3 problems? ')_Manghiiot a_Fomiy members b)_ Mice Berend, ‘2)_Doctor Z “| Priesu Church leader Abbaye @)_ Relatives e) Nurse e)_Barangay haa “Others (pec) Others (sec) “FL lrimunization status of family members or problems other tran health, wriom do you consult? Tone. Tacoma Complete “Type cfimmunzation EPI Tor under five chidren b)_COVIO vaccines for ages Syears and older ) Others (spect) 3 Physical and mental health ‘Does members ofthe family have had adequate. YE NO. ‘@)_Restand seep D)_Exercse ‘@)Relaxaon actos ‘@)_ Stress management actives Environment a) Kind of neighborhood URGAN By Social and health facies available co Bagy Hale Gate Communication end ansportation faites Hot —eraraness of commaniy Organisation, a SP renenten ae fary eve foieg | eananon inthe communi Foes a pairs panriaor | Nevorarerea Te Teyaravere The YESINO 5 Sy Fraw are you vowed ns ates? (BOT 1 Riond mestnas 7 Give donations 3, Panning plementation we box ransweris Yes)WESLEYAN UNIVERSITY-PHILIPPINES ‘COMMUNITY HEALTH NURSING | ‘FAMILY ASSESSMENT GUIDE. a Lenght resienor Years» ; - pop Cab: Wife [SH Gad "| Naw Brethur in-law | Hs_Grur? | Nowe on Hp Wek Head [ahi ad | Goan 5 Vunalyi, F-Ordoneg | 24 Jaime B- Savior Rh pein y-Ordonio | 4 Ténathon f+ Ordenio | 2, TE FAMILY STRUCTURE (Uck the appropriate Dox) Woclear wri‘Above 10,000 18,000, ‘baie 40, 000 ~ 60,000 00 ‘Above 15,000 20,000 Thor tian 60,000 00 1. Father Good 2 Maher Geod = chiaren Covell 4 Other mentors ofthe family (nica who) TSA IDENTIFY AND RANK ACCORDING 10 PRIORITY a] ey a] oy sy un (Nine CEE Ee NO. Ts your tot owned? 2s your house owned? '3._Is the ving space adequate? S What are the appliances owned “4. Type of housing material Type af garbage dlaposal by the family? ‘a Wood a1 Collected B._Concreie ZB tie re bee ._ Waste segregation e_mibed © Pie ovltr Feeding to animals E_-makeshi é ‘&_ Open duping others (SpeaH) e ‘uring t burying | % throw inthe rverTeewer te others (apeciy) Type of waste disposal Type of drainage systom ‘37 Souree of water suppiy atu “&_Open ZL = Owned wrap and vow B._ Closed Bought water scaled e_shared cit py Z others (65657) others (spec) "70 Drinking Water Storage 7TH, Contalnors Used for water TE, Food storage a. Refrigerated a. Plas picher Covered B Covered Bote. Uncovered uncovered Jar, cay pots e._Refigerator ‘&_Others (speci) &_Cabinet z ‘8. Others pec) 73, Cooking fa Gas slove Elecic ove ‘charcoal wood ‘Others “14. Common pests found at home, Ais Flos Bod bugs Rats Termes, Mice cockroaches ‘thers (epecfy), 16, Are thore breeding sites for these, pests? a_YES NO. "Note: specify what pastea Sa PetsfanimalsKeptin he homelyard 4, Are there aouldent hazards = 3 1 Present in the home? 2 3. YES : BOO a NOTE: speci wha Rand : t g PELE Sa Luss ees ‘1.__Gommon liinesses suffered inthe last § months and the treatment applied ‘COMMON TLNESS TREATHENT APPLIED probleme olor than healt, whom do you consul? | 3) _Manghiit a Faniy members | b) Nici Friends | ‘Doctor e)_Pries Co aS | d)_ Abu cd) Relates 3}_Nurso )Berangay EE 1) Ohers pec others pect) “% Immunization status of family members “Type of immunization one incomplete Complete “EPI Tor under five children S 8) COVID vaccines forages S years and oder ‘Others (spect) Physical and mental Falth | Does menbers oth andy have had adele. os | a) Rest and leer La D)_ Eero Zz ©) Reimation aces @)_Stress management ecives Environment ') Kind of neighborhood PbS | ‘By Social and heath Yociiies avaiable Rope Fath Code 2) Communication and transportation facies otra | [eC awareness of commonity Organization 3} Are member ofthe fay aware ofexising | YES 1 se ee ‘re you a meber of tie “ie you aware of By Provide names of organizations that you know