COLLEGE OF NURSING

CARLATAN, SAN FERNANDO, LA UNION

FAMILY ASSESSMENT GUIDE

TALLY SHEET
Place of Origin: BRGY. SINALBAG

Legend: S1- CASEM, AN. ; S2- CASEM, MN. ; S3- SURTIN, M.

; S4- SURTIN, LA. ; S5- CASEM, C. ; S-6- CASEM, AD

Total Population: 6
Total No. of Males: 3
Total No. of Females: 3
No. of Families: 6
No. of School Children: 1

I. HOUSEHOLDS: 4

II. FAMILY DATA

A. Length of Residency:
S5 S6
S1 S2 S3 S4 TOTAL

0-10 years 0 0 0 0 0 0 0

11-20 years 0 0 1 1 0 0 2

21-30 years 0 0 0 0 0 0 0

31-40 years 0 1 0 0 0 0 1

41-50 years 1 0 1 0 0 0 2

51-60 years 0 0 0 0 0 0 0

61-70 years 0 0 0 0 0 0 0

71-80 years 0 0 0 0 1 1 2

81-90 years 0 0 0 0 0 0 0

91-100 years 0 0 0 0 0 0 0

There are 2 person length of residency is around 11-20

years
There are 2 person length of residency is around 71-80
years
There is 1 person length of residency is around 31-40 years
There is 1 person length of residency is around 41-50 years
. B.Family Size:
S6 TOTAL
S1 S2 S3 S4 S5
1-5
0 0 0 0 0
members
6-10 6
1 1 1 1 1
1
members
11-15
0 0 0 0 0
members

The household size of the family that we Interviewed is 6-10 members.

C. Religion:
S5 TOTAL
S1 S2 S3 S4 S5

Catholic 1 1 1 1 1 1 6

INC 0 0 0 0 0

Evangelica 0 0 0 0 0

Pentecost 0 0 0 0 0

Born Again 0 0 0 0 0

Jehovas 0 0 0 0 0

All of the family members are Roman Catholic.

III. FAMILY MEMBER’S CHART
A. AGE
S1 S2 S3 S4 TOTAL

0-10 years 0 1 0 0 1

11-20 years 0 1 5 2 8

21-30 years 2 3 0 0 5

31-40 years 1 0 0 0 1

41-50 years 0 1 2 2 5

51-60 years 1 1 0 0 2

61-70 years 0 0 0 0 0

71-80 years 0 0 1 0 1

81-90 years 0 0 0 0 0

91-100 years 0 0 0 0 0

There is 1 person age which ranges 1-20 years old.

There is 1 person age which ranges 31-40 years old.
There are 2 person age which ranges 41-50 years old
There are 2 person age which ranges 71-80 years old.

B. SEX
S6 TOTAL
S1 S2 S3 S4 S5

Male 0 0 1 1 1 0 3

Female 1 1 0 0 0 1 3

The sex of the family is equal which is 3 male and 3 female.

C. CIVIL STATUS
S6 TOTAL
S1 S2 S3 S4 S5

Single 0 0 0 1 0 0 1

Married 1 1 1 0 1 0 4

Widowed 0 0 0 0 0 1 1

Separated 0 0 0 0 0 0

Live-in 0 0 0 0 0 0

Most of them are married and there is 1 single and 1 widowed.

D. EDUCATIONAL ATTAINMENT
 S6 TOTAL
S1 S2 S3 S4 S5

Day Care/Kinder 0 0 0 0 0 0 0

Pre-school 0 0 0 0 0 0 0

Elementary 0 0 0 0 1 1 2

High School 0 0 0 0 1 0 1

College Graduate 0 0 0 0 0 0 0

Vocational 1 1 0 0 0 0 2

4 years old and 0 0

0 0 0 0 0
below
Undergraduate 0 0 1 0 0 0 1

There are 2 which Educational Attainment is Elementary and also there are 2
vocational and there is 1 undergraduate and 1 high-school student. .
IV. FAMILY CHARACTERISTICS
A. Type of Family Structure:
S2 S6
S1 S3 S4 S5 TOTAL

Extended 1 1 1 1 1 1 6

Matriarchal 0 0 0 0 0 0 0

Nuclear 0 0 0 0 0 0 0

Patriarchal 0 0 0 0 0 0 0

Living Alone 0 0 0 0 0 0 0

Egalitarian 0 0 0 0 0 0 0

They are all in Extended Family.

B. Family Dietary Habits

What did you eat yesterday? (24 Hour Dietary Recall)
Breakfast S1 S2 S3 S4 S5 S6 TOTAL

a. Rice 1 1 1 1 1 1 6

b. Bread 0 0 0 0 0 0 0

c. Egg 0 0 0 0 0 0 0

d. Vegetables 0 0 0 0 0 0 0

e. Coffee 1 1 1 1 1 1 6

f. Cereal 0 0 0 0 0 0 0
 g. Fish 1 1 1 1 1 1 6

h. Meat 0 0 0 0 0 0 0

i. Fruit 0 0 0 0 0 0 0

Lunch S1 S2 S3 S4 S5 S6 TOTAL

a. Rice 1 1 1 1 1 1 6

b. Vegetables 1 1 1 1 1 1 6

c. Egg 0 0 0 0 0 0

d. Fish 1 1 1 1 1 1 6

e. Canned goods 0 0 0 0 0 0

f. Bread/Biscuits 0 0 0 0 0 0

g. Frozen foods 0 0 0 0 0 0

h. Meat 0 0 0 0 0 0

i. Seafoods 0 0 0 0 0 0

Dinner S1 S2 S3 S4 S5 S6 TOTAL

a. Rice 1 1 1 1 1 1 6

b. Vegetables 0 0 0 0 0 0 0

c. Frozen 0 0 0 0 0 0 0

d. Fish 0 0 0 0 0 0 0

e. Meat 0 0 0 0 0 0 0

f. Fruit 0 0 0 0 0 0 0

g. Canned Goods 1 1 1 1 1 1 6

Most of the households prefer eating rice, fish & vegetables.

C. Monthly Family Income Source
S2 TOTAL
S1 S3 S4 S5 S6

Below 1000 0 0 0 0 0 0 0

1000 - 4999 0 0 0 0 0 0 0

5000 - 9999 1 1 1 1 1 1 6

10000 - 14999 0 0 0 0 0 0 0

15000 - above 0 0 0 0 0 0 0

The family are in or above middle class when it comes to income.

V.FAMILY HEALTH STATUS/HEALTH HISTORY (in a year)

Father S1 S2 S3 S4 S5 S6 TOTAL
a. Joint Pain 0 0 0 0 0 0 0

b. HPN 0 0 0 0 0 0 0

c. Asthma 0 0 0 0 0 0 0

d. UTI 0 0 0 0 0 0 0

e. Edema 0 0 0 0 0 0 0

f. Liver Disease 0 0 0 0 0 0 0

g. TB 0 0 0 0 0 0 0

h. Cough and 0 0
0 0 0 0 0
Colds
I. Heart 0 0
0 0 0 0 0
Problems
j. Low Vision 0 0 0 0 0 0 0

k. Arthritis 0 0 0 0 0 0 0

l. Anemia 0 0 0 0 0 0 0

m. Cataract 0 0 0 0 0 0 0

n. Headache 0 0 0 0 0 0 0

Mother S1 S2 S3 S4 S5 S6 TOTAL

a. Anemia 0 0 0 0 0 0 0

b. HPN 0 0 0 0 0 0 0

c. Cough and 0 0 0 0 0 0 0
Colds
d. Asthma 0 0 0 0 0 0 0

e. Diabetes 0 0 0 0 0 0 0

f. UTI 0 0 0 0 0 0 0

g. Arthritis 0 0 0 0 1 1

h. Cataract 0 0 0 0 0 0 0

i. Stroke 0 0 0 0 0 0 0

j. Mumps 0 0 0 0 0 0 0

k. Deaf 0 0 0 0 0 0 0

l. Allergy 0 0 0 0 0 1 1

m. Hypertension 0 0 0 0 0 1 1

n. Edema 0 0 0 0 0 1 1
 o. Hypotension 0 0 0 0 0 0 0

Children S1 S2 S3 S4 S5 S6 TOTAL

a. Asthma 0 0 0 0 0 0 0

b. Cough and 0 0
0 0 0 0 0
Colds
c. Fever 0 0 0 0 0 0 0

d. Allergy 0 0 0 0 0 0 0

e. Anemia 0 0 0 0 0 0 0

f. LBM 0 0 0 0 0 0 0

g. Toothache 0 0 0 0 0 0 0

h. UTI 0 0 0 0 0 0 0

i. Headache 0 0 0 0 0 0 0

The only member of the family which has health problems is the mother
which are arthritis, hypertension, allergy & edema.

VI. FELT FAMILY NEEDS (Identify and rank according to priority)

S3 S4
S1 S2 S5 S6 TOTAL Rank

Money 1 1 1 1 1 1 1 1

Food 1 1 1 1 1 1 1 2
Kitchen Utensils 1 1
and Requirements 1 1 1 1 1 3
Rice 1 1 1 1 1 1 1 4

Most of the families recognized Money as their primary family need.

VII. HOME AND ENVIRONMENT

Is your lot owned? S1 S2 S3 S4 S5 S6 TOTAL

Yes 1 1 1 1 1 1 6

No 0 0 0 0 0 0 0

Is your house
owned?
 Yes 1 1 1 1 1 1 6

No 0 0 0 0 0 0 6

They owned a house and lot.

A. Type of Housing Material
TOTAL
S1 S2 S3 S5 S6

Wood 0 0 0 0 0 0

Mixed 1 1 1 1 1 6

Concrete 0 0 0 0 0 0

The house of the family is made with mixed wood and concrete.
B. Appliances owned by the family
S6 TOTAL
S1 S2 S3 S4 S5

TV 1 1 1 1 1 1 6

Refrigerator 1 1 1 1 1 1 6

Computer/laptop 0 0 0 0 0 0 0

Gas range/stove 1 1 1 1 1 1 6

Radio 1 1 1 1 1 1 0

Motorcycle 0 0 1 0 0 0 1

Cellphone 1 1 1 1 0 0 4

Electric Fan 1 1 1 1 1 1 6

Washing Machine 0 0 0 0 0 0 0

Rice Cooker 0 0 0 0 0 0 0

Bike 0 0 0 0 0 0 0

Coffee maker 0 0 0 0 0 0 0

Flat iron 0 0 0 0 0 0 0

Van 0 0 1 0 0 0 1

The family have most of the necessary appliances for living.

C. Type of Garbage Disposal

S6 TOTAL
S1 S2 S3 S4 S5

Collected 1 1 1 1 1 1 6
 Waste Segregation 0 0 0 0 0 0 0

Feeding Animals 0 0 0 0 0 0 0

Open Dumping 0 0 0 0 0 0 0

Burning 0 0 0 0 0 0 0

Burying 0 0 0 0 0 0 0

The family type of disposal is Collected.

D. Type of waste disposal:
S6 TOTAL
S1 S2 S3 S4 S5

Flush 0 0 0 0 0 0 0

Wrap and Throw 1 1 1 1 1 1 6

Dig and Bury 0 0 0 0 0 0 0

Water Sealed 0 0 0 0 0 0 0

Pit-Privy 0 0 0 0 0 0 0

The family is using wrap and throw for their wastes.

E. Types of drainage system
S6 TOTAL
S1 S2 S3 S4 S5

Open 1 1 1 1 1 1 6

Closed 0 0 0 0 0 0 0

The family are using open drainage system

F. Source of water
S6 TOTAL
S1 S2 S3 S4 S5

Owned 1 1 1 1 1 1 6

Spring 0 0 0 0 0 0 0

Bought 0 0 0 0 0 0 0

Well 0 0 0 0 0 0 0

Shared 0 0 0 0 0 0 0
 The family owned a source of water.

G. Drinking water storage

S6 TOTAL
S1 S2 S3 S4 S5

Refrigerated 1 1 1 1 1 1 6

Covered 1 1 1 1 1 1 6

Uncovered 0 0 0 0 0 0 0

All of the drinking storage of the family are refrigerated and covered.

H. Container used
S6 TOTAL
S1 S2 S3 S4 S5
Plastic/ Pitcher/ 1 6
1 1 1 1 1
Canister
Jags 0 0 0 0 0 0 0

Bottles 0 0 0 0 0 0 0

Jars/Clay Pots 0 0 0 0 0 0 0

Their drinking water are contained in a plastic/ pitcher/

canister
Food storage/ cooking facilities
S6 TOTAL
S1 S2 S3 S4 S5

Covered 1 1 1 1 1 1 6

Cabinet 0 0 0 0 0 0 0

Ref 1 1 1 1 1 1 6

Stove 1 1 1 1 1 1 6

Uncovered 0 0 0 0 0 0 0

Pots/Pans 1 1 1 1 1 1 6

Refrigerator are used as a food storage and all of them are covered. They also
using stove and pots/pans for cooking their food.
VIII. HEALTH & HEALTH PRACTICES
A. Common illnesses encountered for the last 6 months and treatment
applied
S6 TOTAL
S1 S2 S3 S4 S5

Coughs and colds 0 0 0 0 0 0 0

 Hypertension 0 0 0 0 0 1 1

Headaches / 1 1
0 0 0 0 0
Migraine
Stomach pains 0 0 0 0 0 0 0

Diarrhea 0 0 0 0 0 0 0

Toothache 0 0 0 0 0 0 0

Arthritis 0 0 0 0 0 1 1

Edema 0 0 0 0 0 1 1

Allergy 0 0 0 0 0 1 1

Gastritis 0 0 0 0 0 0 0

The illness that they encountered for the last 6 months are hypertension,
headaches, arthritis, edema, & allergy.
B. Whom do you consult for health-related problems?
S6
S1 S2 S3 S4 S5 TOTAL
Manghihilot 0 0 0 0 0 0 0

Self Medication 0 0 0 0 0 0 0

Clinic 1 1 1 1 1 1 1

Doctor 1 1 1 1 1 1 1

Midwife 0 0 0 0 0 0 0

Albularyo 0 0 0 0 0 0 0

BHW 0 0 0 0 0 0 0

All of them seek help from the doctor and go clinic for their health
problems.

C. For problems other than health, whom do you consult?

S6 TOTAL
S1 S2 S3 S4 S5

Family members 1 1 1 1 1 1 6

Priest 0 0 0 0 0 0 0

Relatives 1 1 1 1 1 1 6

Friends 0 0 0 0 0 0 0

Barangay 0 0
0 0 0 0 0
Officials
Doctor 0 0 0 0 0 0 0
 In case of problems aside from health, members usually consult their
family members and relatives.
D. Immunization status of family members:
S6
S1 S2 S3 S4 S5 TOTAL

Complete 1 1 1 1 1 1 6

None 0 0 0 0 0 0 0

All of them have complete immunization.

E. Have you had adequate…
S6
S1 S2 S3 S4 S5 TOTAL

Rest

Yes 1 1 1 1 1 1 6

No 0 0 0 0 0 0 0

Exercise

Yes 1 1 1 1 1 1 6

No 0 0 0 0 0 0 0

Relaxation
Activities
Yes 1 1 1 1 1 1 6

No 0 0 0 0 0 0 0

Stress
Management
Yes 1 1 1 1 1 1 6

No 0 0 0 0 0 0 0

All of them have adequate rest, exercise, adequate, relaxation activities 7stress
management.

IX. KIND OF NEIGHBORHOOD

A. Kind of neighborhood
S6
S1 S2 S3 S4 S5 TOTAL
 IP 0 0 0 0 0 0 0

Relative 1 1 1 1 1 1 6

All of their neighbors are their relatives.

B. Communication and transportation
S6
S1 S2 S3 S4 S5 TOTAL

Cellphone 1 1 1 1 0 0 4

Motor 0 0 1 0 0 0 1

Tricycle 0 0 1 0 0 0 1

Van 0 0 1 0 0 0 1

Jeep 0 0 0 0 0 0 0

Verbal 1 1 1 1 1 1 6

Walking 1 1 1 1 1 1 6

The family mode of communication are cellphone and verbal while

their transportation are motor, tricycle & van.

X. AWARENESS OF COMMUNITY ORGANIZATION

A. Are you aware of the existing organizations in the community?
S6
S1 S2 S3 S4 S5 TOTAL

Yes 1 1 1 1 1 1 6

No 0 0 0 0 0 0 0

B. Are you a member of these organizations?

S6
S1 S2 S3 S4 S5 TOTAL

Yes 0 0 0 0 0 1 1

No 1 1 1 1 1 0 5

C. How are you involved in its activities?

S6 TOTAL
S1 S2 S3 S4 S5

Attend meeting 0 0 0 0 0 1 1

Planning 0 0 0 0 0 0 0
 Give donations 0 0 0 0 0 0 0

Implementation 0 0 0 0 0 0 0

Evaluation 0 0 0 0 0 0 0

All of the family members are aware of the existing organizations in the
community but only 1 is member and involved in its activities.
D. Formal and non-formal leaders of the community whom you think can lead
the people
S5
S1 S2 S3 S4 S6 TOTAL

Mayor 0 0 0 0 0 0 0

LGU 0 0 0 0 0 0 0

Pastor/Priest 0 0 0 0 0 0 0

Captain 0 0 0 0 0 0 0

Barangay 0 0
0 0 0 0 0
officials
Vice Mayor 0 0 0 0 0 0 0

DAR 0 0 0 0 0 0 0

Governor 0 0 0 0 0 0 0

Teacher 0 0 0 0 0 0 0

BHW 0 0 0 0 0 0 0

0 0
IP Leader 0 0 0 0 0

Tanod 0 0 0 0 0 0 0

They think that no formal and non-formal leaders can lead their
community.
Problem Identified:
• Allergies
- 1 out of 6 member of the family in Brgy. Cabalitocan had allergies.
• Edema
- 1 out of 6 member of the family in Brgy. Cabalitocan had edema.
• Headache
- 1 out of 6 member of the family in Brgy. Cabalitocan had headache.
• Hypertension
- 1 out of 6 member of the family in Brgy. Cabalitocan had hypertension.
• Arthritis
- 1 out of 6 member of the family in Brgy. Cabalitocan had arthritis.

Prepared by: