MABINI COLLEGES, INC.

Governor Panotes Avenue,

Daet, Camarines Norte
Tel. no. (054) 721-1281 local 102
Email: mabinicollege@hotmail.com

FAMILY HEALTH ASSESSMENT TOOL

Key Informant: __________________________ Contact Number: ___________________

Primary Health Center: _________________________________
Address: ________________________________
Interviewed by: ____________________ Date of interview: _________________
(Name of Student)

1. IDENTIFICATION INFORMATION
Head of Family: ______________________

Occupation: _ ________________________ Monthly Income: ____________________

Address: _______________________________

Type of Family: Nuclear Joint/Extended Others:_________________

Religion: Roman Catholic Muslim Christian Hindu/Mormons

Jehovah’s Witness Iglesia ni Cristo Dating Daan
Any other Pls. Specify: ___________________

Length of Residency: _________________

Ethnicity: __________________________

2. HOUSING CONDITION
I. Type of House: Completed Partially Completed Independent

Material: Light Mixed Strong

Ownership: Owned Rented Others: _________________

a. Room Number for sleeping: _________

b. Kitchen: Separate Part of the house

Cooking Facility: Electric Stove Gas Stove Firewood/Charcoal

Others: ____________________

Drainage Facility: Open Blind None

Sanitary Condition: ________________________________

c. Lighting Facilities: Electricity Kerosene

Others (specify):__________
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 d. Ventilation: Number of windows: __________ Good ( ) Poor ( )

e. Bathroom: Separate Common

f. General Drainage: Open Closed

II. Water Source

a. Drinking Water

Source: Tap/CNWD Refilling Station Boiled Water

Stoarge: Refrigerator Covered Uncovered

b. Household Use
Source: Hand Pump Tap/CNWD Deep Well
Others: ______________
Storage: Direct from faucet Covered Container
Uncovered Container

III. Waste Disposal

a. Garbage
Method: Composting Burning Burying
Collected Others: __________________
b. Toilet
Type: Pall System Antipolo System Overhung Latrine
Flush Type Open Pit Privy Closed Pit Privy
None Others: ______________

IV. Domestic Animals

Kind Number Where Kept Sanitary Condition
__________ _____ ____________________ __________________________
__________ _____ ____________________ __________________________
__________ _____ ____________________ __________________________
__________ _____ ____________________ __________________________
__________ _____ ____________________ __________________________
__________ _____ ____________________ __________________________
__________ _____ ____________________ __________________________

3. FAMILY COMPOSITION

BIRTHDATE OCCUPATION
RELATIONSHIP
(mm-dd-yyyy) (Type-Place) IMMUNIZATION
SN NAME WITH HEAD AGE SEX HEALTH STATUS
EDUCATION STATUS
OF FAMILY
(Highest Attainment)

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1

10

11

12

4. TRANSPORT AND COMMUNICATION FACILITIES

Owned: Yes No
Tricycle Bicycle Padyak Bus Taxi
Car PUV Jeepney Others:_________

Telephone
Internet
Television
Radio
Newspaper/Magazine
Cellphone

5. LANGUAGE KNOWN
Filipino Ilocano Bicol
English Bisaya Any Other: _________________

6. A. NUTRITIONAL PATTERN
_____VEGETARIAN _____NON-VEGETARIAN
Staple Food: Rice Wheat Mixed
Vegetables: Grown Purchased Quantity used per day: ___gm/kg
Milk: Quantity used per day: ___ liters
Non-vegetarian dish: Specify: __________ How often: ___________

B. NUTRITIONAL STATUS OF FAMILY MEMBERS

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 Name of Member Nou Re
rish mar
ed/ ks
Und
er
Nou
rish
ed
Sex Age Height Weight BMI
Obese
Overweight
Normal
Wasted
Severely wasted

- When was the last time you visited the doctor/health center for a routine check-up?
Within the last 12 months Within the last 2 years
Between 2-5 years Over 5 years ago
I have never had a routine check-up/visit
- Are you able to visit a doctor/health care worker when needed?
Always Sometimes Seldom Never
- Which of the following have stopped you from getting the health care you need? (Check all that
apply)
Too expensive
Lack of transportation
Health worker is not attending
Others, please specify: ________________________________

7. RECORD OF PAST ILLNESS (FOR THE PAST YEAR)

CHECK- INVESTIGATION Remarks
NAME AGE ILLNESS/CONDITION DURATION TREATMENT
UP DONE
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 Yes l NO

- Select any of the following preventive procedures you have had in the last year.
Vaccination, please specify ___________________________
BP Check-up Prostate screen
Cholesterol screen Dental cleaning
Blood Sugar check Mammogram
ECG Colon/Rectal Examination
Vision screening Pap smear
Hearing screening Others, please specify _________________

8. CURRENTLY PREGNANT WOMAN

I. PROFILE
Name: ________________________________ Contact Number: _____________________
Age: ____ Occupation: ________________ Educational Attainment: ____________________

II. GENERAL HEALTH STATUS

BP: ______ HEIGHT: ______ WEIGHT: ________
Tetanus Toxoid status

TT1 TT2 TT3 TT4 REMARKS

ImmunizationTT5
DATE GIVEN

Other immunization, please specify: ________________________________

Any current medical condition/sickness: _____________________________
Any health concern: _____________________________________________

III. OBSTETRIC HISTORY

1. Number of pregnancies: _______________
2. Number of preterm deliveries: _______________
3. Number of full term deliveries: _______________
4. Numbers of still births: _______________
5. Number of live births: _______________
6. Number of abortion: (spontaneous) ______ (induced) _____
7. Number of ectopic pregnancies: _______________

Length of Normal (N) or Complications with

Child Date of Birth Sex
Labor Caesarian (CS) pregnancy or delivery

IV. MENSTRUAL AND GYNECOLOGICAL HISTORY

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 1. Are your periods regular? __ YES __ NO
2. Do you have spotting in between your menstruation? __ YES __ NO
3. Age at first menstrual period ___
4. Number of days from the first day of menstruation to the last day of next period (menstrual
cycle) in days: _________
5. Length/duration of menstrual flow: _______ days
6. Is your menstrual flow ____ LIGHT _____ MODERATE _____ HEAVY
7. Are your periods painful? __ YES __ NO
8. Do you have any other symptoms/manifestations with your period? __ YES __ NO
If yes, what are they? ______________________________
9. Have you had any pap smear test? __ YES __ NO
If YES, when? _______________________________________________
What was the diagnosis? ______________________________________
How are you treated?
___________________________________________________________________________
___________________________________________________________________________
IF NOT PREGNANT:
10. Are you currently using contraceptive or birth spacing method? __ YES __ NO
If YES, what method are you using? __________________________________
If NO, have you ever used any contraception or birth spacing method in the past?
__ YES __ NO
If YES, what method are you using in the past? _________________________________
Why are you not using it now? ______________________________________________
________________________________________________________________________
________________________________________________________________________

If NO, why have you not used a contraceptive or birth spacing method? _____________
________________________________________________________________________
________________________________________________________________________

9. HEALTH
a. Where do you go if you or any of your family member is sick? ___________________
b. Who do you consult when you or any of your family member is sick? _____________
c. When was the last time you or any of your family member had consultation/visit to the
doctor? ___ __ For what reason: _______________________________
d. When was the last time you or any of your family member visit a dentist? ________________
e. Is there any medication that is currently being taken by you or any of your family member?
If YES, please name them: ________________________________________________
f. Is any member of the family currently with sickness or condition? ___ YES ____ NO
What is the sickness/medical condition? ___________________________________________

h. Is their death in the family for the past year? ___ YES ____ NO
If YES, for what reason? _________________________________________________________
i. Have you attended any health-related meetings or seminar? ___ YES ____ NO
If YES, what is the topic? __________________________________________________________
If NO, what is the reason why you don’t attend a health-related seminar, meetings, and the like?
_____________________________
j. Which of the following do you think are the FIVE most important factor a healthy community? Please
check 5 only.
_____ Child care
_____ Prenatal/Postnatal care
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_____ Low death rate
_____ Low illness rate
_____ Healthy behavior and lifestyle
_____ Healthy food sources
_____ Clean and safe environment
_____ low level of child abuse
_____ Emergency and disaster preparedness
Others, please specify: ___________________________________________________________