University of Bohol

College of Nursing
City of Tagbilaran

Family Health Assessment Form

Family Surname: _________________________ Name of Family Head___________________________

House Number_____________ Street__________________________Purok Number _______________
Purok Name: _________________Barangay_____________________Municipality_________________
Source of Information: _____________________________________ Relation ____________________
Data Gathered By: _________________________________________ Date: ______________________

A.Household Members:

No Family Sex Age Civil Relation Religion Educational Occupation

. Status to Head Attainment
Members
B. Family Characteristics:
Type of family structure

() Nuclear Family () Dyad Family () Compound Family

() Extended Family () Blended Family () Cohabiting Family () Single Parent Family

Name Age Relationship Location of Occupation/ Frequency Means of

to Head member Work of Contacts communication

Family Mobility
Length of time of current address:_____________________________________________
Address of Previous Residence: ________________________________________________
Frequency of geographic move: ________________________________________________

Family Dynamics:
Emotional Bonding of Family Members__________________________________________
Distribution of Authority and Power ____________________________________________
How members communicate__________________________________________________

Dominant Members in terms of decision making __________________________________

() Husband () Wife () Adult Children () Others (specify) _______________

How are problems solved? ____________________________________________________

How is conflict handled? ______________________________________________________
Division of labor _____________________________________________________________

C. Socio Economic and Cultural Characteristics

Family Social Integration:
Languages or Dialect(s) Spoken :
() Visayan/ Cebuano () Tagalog () English () Others (specify) ____________________

Literacy (Ability to read and Write in language(s)

() Yes () No

Degree of social network with friends, neighbors and other relative _____________________

Network with religious organizations (name of organization of which the family members are involve)

_______________________________________________________________________________

Network with Social Organizations (name of the organizations of which family members are involve)

_______________________________________________________________________________

Educational experience____________________________________________________________

Work Experience _________________________________________________________________

Adequacy of Financial Resources:

Monthly Family Income source
Husband: ____________________ Wife______________ Others (specify)______________

Total Monthly Family Income: (please check)

() below P5000 () P21, 000-P30, 000

() P6, 000- P10, 000 () P30, 000-P40, 000
() P11, 000-P15,000 () P40,000- P50, 000
() P16, 000- P20, 000 () Above P50,000
Identify and rank according to priority family needs:
1.
2.
3.
4.
5.

Leisure Time (Name some leisure time activities you are interested at)________________________

___________________________________.

D. Cultural Influences: Values/Attitudes/Beliefs about

Spirituality___________________________________________________________
Rituals (Holidays and Celebrations) _______________________________________
Health ______________________________________________________________
Folk diseases _________________________________________________________
Traditional Healer _____________________________________________________

E. Family and Environment

1. Home
a. Ownership- () owned () rented () rent free

b. Construction Material
() light () mixed () Strong

c. Number of bedrooms:____

d. Lighting facility
() Electricity () Kerosene () Others (specify)_________________

e. General sanitary condition ______________________________________

2. Drinking and Water supply

a. source
Level 1 – (point source)

() shallow or deep well () improved Dug Well

() Developed spring () rain tank

Level 2 (communal faucet)

 () waterworks system () Water refilling station

b. Distance from the house____________________________________________

c. Storage:
() None (direct from the faucet)
() Large covered container with faucet
() Large uncovered container with faucet
() Others (specify)___________________

3. Kitchen

a. Cooking facility used:

() electric stove () Gas stove
() firewood /Charcoal () Others (specify)________________

b. Food storage:
() Covered () Uncovered () Refrigerator
() container with cover
() container without cover

c. sanitary condition:____________________________________________________

d. Drainage facility of kitchen:

() Open drainage
() blind drainage
() None

4. Waste Disposal

a. Garbage container

() covered () Open () none

b. Method of disposal

() Hog feeding () open burning () Open dumping

() garbage collection () burying in pit ()Composting

() Others (specify) _________________________

c. Excreta disposal:
 () Tank flush toilets (connected to septic tanks with sewerage system)

() Pour-Flush Latrine

() Ventilated-improved pit latrine

() Overhung latrine

() Antipolo toilet

() Pit latrine

() box and can privy

() Shared

() none

d. Distance from the house ______________________

e. Sanitary condition (describe briefly the state of cleanliness) __________________________

5. Domestic animals/common household pets

Kind Number Place kept

 6. Pest and Vermin Control: Presence of breeding sites of insects, rodents, etc.

() Yes; specifically: ____________________________________________

() No

7. Presence of Accident Hazards: () Yes () No

If yes, Specify_______________________

() Broken parts of the house () Medicines (not kept)

() Sharp Objects (not kept) () Broken glasses

() stray animals

F. Family Neighborhood

a. Location: () urban () rural () subdivision () slum area

b. Type: () residential () Semi Commercial

c. Safety: () traffic patterns () Lighting () security ( private. /police)

() pedestrian lanes () walking pathways

d. Population Density (crowding)

() congested () non congested

e. Sources of pollution

() air () water () Soil () noise

f. Social and health facilities available

() Barangay Health Station () Rural Health Units

() Private Clinics/Hospitals () Barangay Hal

() Chapel () Senior Citizen’s Hall

 () basketball court () Purok Kiosk

g. Communication facilities of the family

() cellphone

() landline Telephone

() Computer/Laptop connected to internet

h. Transportation Facilities:

() Public Utility vehicle

() owned private cars

() own motorcycles

() rented vehicles

G. Family Health/Behavior

a. Activities of daily living (How the family spends a typical day)___________________________

_________________________________________________________________.

b. Health History:

1. Pregnancy:_________________________________________________________________

2. Illness: ____________________________________________________________________

3. Death within the past 5 years: () Yes () No

4. Health Attendance: (How Often)

() every month () once a year

() as the need arises () never () Others (specify)___________________

c. Self -Care Activities (name family’s related activities) __________________________________

d. Risks Factor assessment for specific lifestyle diseases:

() Hypertension () Physical inactivity

() Sedentary lifestyle () Cigarette/tobacco smoking

() Elevated lipids/cholesterol () Alcohol drinking

() Obesity () diabetes mellitus

() inadequate fiber intake () Stress

() poor diet () Substance abuse

() others (specify)_______________________________

e. Present Health Status:

A. Father/Head of the family: ____________________________________________________

Vital Signs: T-_____________ BP______________ HR____________ RR _______________

Physical complaints: _________________________________________________________

B. Mother/ Wife:______________________________________________________________

Vital Signs: T-_____________ BP______________ HR____________ RR _______________

Physical complaints:________________________________________________________

C. Other members: ____________________________________________________________

Vital Signs: T-_____________ BP______________ HR____________ RR _______________

Physical complaints: _________________________________________________________

f. Common Illness encountered and management done

Age Illness Management

0-1
 1-3

3-6

6-7

7-12

13-18

19-25

26-35

36-45

46-50

51-55

56-60

60-up

g. Health Care Resources

a. Where do you consult for health related problems?

() “Manghihilot”/ Albularyo () BHW’s

 () Physician/Doctor () RHU (MHO, PHN, PHM)

() Alternative treatment Clinics () Others (specify) _________________

b. For Problems other than health, whom do you consult?

() family member () relatives

() Friends () Priest

() Barangay Officials () Health workers

() Others (specify) ____________________________________

c. Immunization status of children:

Are the children immunized? () Yes () No

() Yes, if yes, check immunization received

() BCG () Hep B vaccine
() OPV () AMV
() Pentavalent vaccine () MMR
(DPT, Hep B. Hib)
d. Adequacy of:

1. Rest and sleep: () Yes () No

If No, Why? ___________________________________________

2. Exercise and Physical Activity: () Yes () No

If No, Why? ___________________________________________

3. Stress Management Activity/relaxation: () Yes () No

If No, why? ___________________________________________

If Yes, How often? () Daily () once a week

() Three times a week () once a month

() Never () Others (specify)_______