Family Survey For FNCP

EMILIO AGUINALDO COLLEGE
Gov. D. Mangubat St., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4341-42 www.eac.edu.ph
SCHOOL OF NURSING
COMMUNITY HEALTH NURSING 2

FAMILY HEALTH ASSESSMENT GUIDE
Date of Assessment: _______________________________

Source of information/ informant: _______________________
Head of the family: __________________________________ Contact Number: _______________________
Address: __________________________________________
Religion: __________________________________________
Ethnic background: __________________________________
FIRST LEVEL ASSESSMENT
I. Assessment of the Family, Home, and Environment Conditions
Members of household
Family member Birthdate Highest Occupation

Relation Marital Length of
Rank Name (initials) sex Month Year educ. Type place
to head status Employment
Completed of work
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1. Type of family structure: ( ) Patriarchal ( ) Matriarchal

( ) Nuclear ( ) Extended others: _________________
2. Dominant Family members in terms of decision making, especially in matters of health care
(1.) Name: Age: Sex: Relation to head:
3. General family relationship/dynamics

Presence of observable conflict between members: ( ) Yes ( ) Sometimes ( ) None
If yes/sometimes: state common conflict/s encountered: ___________________________________
How do you resolve conflict? By forgiving each other
Socio- economic Characteristics

1. Family monthly income (average)
2. How much spent for:
Water (monthly): School (fees, materials):
Electricity: Clothing:
Food & grocery needs: Leisure:
Rentals: others:
3. Who makes decision for money matters: specify: __________________
1. Home and Environment

a. Ownership ( ) Owned ( ) Rented ( ) Rent-free
b. Construction materials used ( ) Light ( ) concrete ( ) mixed ( ) makeshift
c. Number of rooms for sleeping:
d. Lighting facilities: ( ) electricity ( ) kerosene ( ) candle others (specify):_____________
e. Adequacy of living space: ( ) small () enough ( ) spacious
f. Sleeping arrangement: ( ) in one room ( ) own rooms ( ) others, Specify___________________
g. General sanitary condition: ( ) dirty ( ) clean ( ) dusty ( ) polluted /dirty with foul-smelling environment
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2. Drinking water supply

a. Source: ( ) private ( ) public
b. Distance from house: Inside the house
c. Water Storage: ( ) none ( )direct from faucet or pipe ( ) large covered container with faucet
( ) large uncovered container without faucet ( ) others:_______
3. Kitchen
a. Cooking facility: ( ) Electric stove ( ) gas stove ( ) wooden/charcoal
b. Sanitary conditions: ( ) clean ( ) dirty ( ) dusty ( ) polluted
c. Drainage facility: ( ) open drainage ( ) blind drainage ( ) none
4. Waste disposal
a. Refuse and garbage ( ) covered container ( ) open ( ) none
Method of disposal:
( ) hog feeding ( ) open burning
( ) open dumping ( ) garbage collection
( ) burried in pit ( ) others; specify:_____________
( ) composting
b. Toilet type:
( ) pail system distance from house:____________________________
( ) over hung latrine ( ) antipolo type
( ) water-sealed latrine ( ) flush type
5. Domestic animals:
Kind Number Place/area where animals are kept
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6. Kind of neighborhood:
( ) congested ( ) slums ( ) village/subdivision others, specify:_________________
Relationship with neighbors and larger community: ______________________
7. Communication facilities available

( ) cellular phone ( ) letters ( ) e-mail ( ) others, specify_____________________________
8. Transportation facilities available

( ) Tricycle ( ) Jeepney ( ) personal vehicle ( ) personal motorbike( ) pedicab ( ) bicycle
others, specify___________________
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SCHOOL OF NURSING
II. Health Status of each Family Member
Family member:
a. Risk factors
__ Hypertension
__ Physical Inactivity
__ Sedentary Lifestyle
__ Cigarette/Tobacco Smoking
__ Elevated Blood Lipids/Cholesterol
__ Obesity
__ Diabetes Mellitus
__ Inadequate Fiber Intake
Stress
__ Alcohol Drinking
__ Substance Abuse
OTHERS: _________
b. Physical assessment indicating presence of illness (diagnosed or undiagnosed by medical practitioners)
c. Results of laboratory/ diagnostic and other screening procedures supportive or assessment findings
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Family member:
a. Risk factors
__ Hypertension
__ Obesity
Stress
__ Alcohol Drinking
__ Substance Abuse
OTHERS: _________
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SCHOOL OF NURSING
Family member:
a. Risk factors
__ Hypertension
__ Obesity
Stress
__ Alcohol Drinking
__ Substance Abuse
OTHERS: _________
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SCHOOL OF NURSING
III. Values, habits, practices on health promotion, maintenance and disease prevention
A. Immunization status of family members (children 0-5 years old)

( ) Fully immunized ( ) Partial / not fully immunized
Name of Child (0-5 years old) Age and birthday List of vaccines received Number of doses
(name of vaccine)
B. Health & lifestyle practices

( ) maintain a balanced diet
( ) drink plenty of fluid/water
( ) eat fruits and vegetables
C. Adequacy of:
Sleep
How many hours a day: 7 hours
Exercise
yes __no if yes; how many times a week:
D. Frequent hand washing:
yes ___ no
Protective Wears
use of footwear when going outside
__ use of mosquito net
use of insect repellent lotion
use of face mask/face shield
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SCHOOL OF NURSING
IV. Use of Promotive-Preventive health services

Do you avail the health services in your barangay?
__ yes __ no
If yes; how often? _______________________
State health services available in your barangay:

1.
2.
3.
4.
5.
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SCHOOL OF NURSING
SECOND LEVEL ASSESSMENT
Validate interview data on realities or experiences regarding performance of the family health tasks:
A. Determine if the family recognizes the existence of the condition/ problem. If the family does not recognize the
presence of the condition/ problem, explore the reasons why.
Sample interview questions:
1. What does the family think about the situation/condition of …..?
2. What do you think is the reason why he/she appears (e.g. thin, lethargic) or, why, do you think he/she is
behaving this way….?
3. What do you think is happening to your….?
4. Why do you think he/she is….. ?
B. If the family recognizes the presence of the condition/ problem, determine if something has been done to maintain
the wellness state or resolve the problem. If the family has not done anything about it, determine the reasons why,
If the family has done something about the condition or problem, determine if the solution is effective.
1. What has been done to improve the condition or situation?
2. What is the family’s plan regarding this?
3. What improvements in the condition of… have been observed?
4. What do you think the family should do about ….?
C. Determine if the family encounters other problems in implementing the interventions for the wellness state/potential,
health threat, health deficit, or crisis. What are these problems?
1. What were the problems or barriers encountered in…..?
2. What do you think are the reasons why there is no improvement in the condition of….?
3. Why did you stop doing what you used to do regarding….?
4. Why did you not continue doing what we have discussed regarding….?
5. How did you do it…?
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SCHOOL OF NURSING
D. Determine how the other family members are behaving towards each other or how they are affected by the health
condition /problem.
1. How are the other members affected by….?
2. How are the other members reacting to…..?
Thank you!
_____________________________
Name & Signature of Student Nurse
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EMILIO AGUINALDO COLLEGE

COMMUNITY HEALTH NURSING 2

Date of Assessment: _______________________________

FIRST LEVEL ASSESSMENT

I. Assessment of the Family, Home, and Environment Conditions

Family member Birthdate Highest Occupation

1. Type of family structure: ( ) Patriarchal ( ) Matriarchal

3. General family relationship/dynamics

Socio- economic Characteristics

1. Home and Environment

2. Drinking water supply

Kind Number Place/area where animals are kept

7. Communication facilities available

8. Transportation facilities available

II. Health Status of each Family Member

b. Physical assessment indicating presence of illness (diagnosed or undiagnosed by medical practitioners)

b. Physical assessment indicating presence of illness (diagnosed or undiagnosed by medical practitioners)

b. Physical assessment indicating presence of illness (diagnosed or undiagnosed by medical practitioners)

A. Immunization status of family members (children 0-5 years old)

B. Health & lifestyle practices

IV. Use of Promotive-Preventive health services

State health services available in your barangay:

SECOND LEVEL ASSESSMENT

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