Appendix A:

FAMILY HEALTH ASSESSMENT FORM

Family Surname: Guab .

House No.: 35 Zone: 2 Street: Barangay: Curva .

Municipality: Cuyapo Province: Nueva Ecija

Source (s) of Information: Genoveva Guab Contact Number: .

Gathered by: Cristina M. Olegario Date: January 26, 2023

HOUSEHOLD MEMBERS:

Name Ag Relationship to Religion Educational Income Occupation Place of

e Head of Attainment Work
Household

Socrates Guab 59 (HEAD) Catholic High School 15k Driver Rizal,

Graduate Nueva
Ecija

Genoveva 62 Mother Catholic High School --------- ----------------- ----------

Guab Graduate

Marco Guab 23 Son Catholic High School 12k Helper San

Graduate Manuel,
(trucking of
Tarlac
goldilocks)

Allaine Trixie 23 Daughter-in- Catholic College --------- ---------------- ----------

Guab law

Astre 1 granddaughter Catholic ------------ -------- ----------------- ------------

Celestine

FAMILY CHARACTERISTICS (Family Members Living Outside the Household)

Name: Age: Relationship (to HOH):

Location of Family member (s): Occupation:
Frequency and duration of contact: Means communication:__________________________
Length of Time at Current Address: ________________________________________________________
Address of previous residences: Frequency of geographic moves: ___________

FAMILY DYNAMICS

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Emotional bonding: close with each other
Distribution of authority and power: The head of the family manages the decision while the mother do
the planning and managing the financial

Degree of individual autonomy: the father

How members communicate: through face-to-face and use of social media
How decisions are made: by talking and discussing with each other
How problems are solved: by having open communication
How conflict is handled: by listening with each other’s opinion
Division of labor:All of the family members have different tasked assigned

SOCIOECONOMIC AND CULTURAL CHARACTERISTICS (Family Social Integration)

Language (s) or Dialect (s) spoken: Filipino, Ilocano. English

Literacy (ability to read and write): all members are literate
Degree of Social Network (friends/neighbors/relatives): well bonded
Network with Social Organizations: None
Educational Experiences: it was such a great experience
Work History:The father was a driver since then and being a helper was the first job of their son
Adequacy of Financial Resources: they are able to manage financial capability as of the moment.

Leisure Time Interests:all of the family members are spending their leisure time browsing the internet

CULTURAL INFLUENCES (Values, Attitudes, and Beliefs About)

Spirituality: they go to church when they have time but not regularly
Rituals (holidays and celebrations: they believe on different rituals like “padasal” and “atang” and etc
and celebrate most of the holidays

Dietary habits:non specific

Health: eating healthy food
Folk diseases: pasma
Traditional healers: hilot, faith healer, herbolarios

FAMILY ENVIRONMENT

Family Residence

Adequacy of size: just enough for all the members

Structural safety: house are made of cement and woods
Water sanitation: pressure tank
Food preparation and storage: buying everyday on the roaming vendor selling fresh goods
Sewage: proper irrigation of man waste under tanks
Garbage disposal: collected by a garbage truck
Excreta disposal: septic tank
Pest and vermin: use insecticidal spray

Family neighborhood

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Location (e.g., urban, rural, subdivision, slum area): rural
Type (e.g residential. Semicommercial): residential

Safety
● Traffic patterns- no road congestion, ● Security (police, or private) – with PNP
with pedestrian lanes headquarters, barangay police or tanod
and CCTV cameras
● Lighting – with streetlights

Population density (crowding): no idea

Sources of pollution
● Air – no burning policy in our town ● Soil- none

● Water – animal waste like rats and ● Noise-none

human waste

FAMILY HEALTH AND HEALTH BEHAVIOR

Activities of daily living(how family spends a typical day): household chores

Health history (pregnancy, illness , death within the past 5 years /health attendance):The mother is
taking maintenance medicine for high blood pressure

Self-care (health promotion and disease prevention): practicing personal hygiene

Risk behaviors: nothing in particular
Health status (problems and priorities: providing immediate response to illness and have urgent referral
to severe condition of the family
Home remedies: herbal medicines, and over- the-counter medicine
Health care resources: Health Center and Infirmary
Health workers: midwife, nurses and physician
Health agencies: Cuyapo Rural Health Unit, Cuyapo Infirmary, Guimba District Hospital

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