MSWD Form Republic of the Philippines

No. 3 Department of Health

Name of
(Name ofthe
Hospital
Hospital)
MSWD Assessment Tool
for Adult
Date of Interview Time of Interview Basic Ward Non-Basic Ward Health Record No. MSWD No.
(Specify) (Specify)

SOURCE OF REFERRAL Address Contact No.

NAME:
Informant Relation to Patient Contact No. Address of Informant

I. DEMOGRAPHIC DATA
Patient Name: Surname First Name Middle Name

Date of Birth Age Sex O Male O Female

Contact No. Place of Birth Gender O Male O Female O LGBTQIA+
Optional
Religion Nationality
Permanent Address Temporary Address

O Single O Married O Common Law O Widowed O Owned O Shared O Rent

Civil Status (Check) Type of Living Arrangement
O Separated ( _ Legally, _ in Fact) O Homeless O Institutionalized

O Primary O Secondary O Vocational Occupation

O Tertiary O Post Graduate Patient's Monthly Income

Highest Educational
O No Educational Attainment PhilHealth Membership Philhealth Membership (Check)
Attainment
Number (PIN) O Direct Contributor
O Indirect Contributor

Family Composition
Relationship to Educational
Name Age Date Birth Civil Status Occupation Monthly Income
Patient Attainment

Other Sources of Income: Household size Total Household income: Per Capita Income:

II. MSWD Classification

O Artisanal Fisher folk
O Financially Capable/Capacitated O Farmer and Landless Rural Worker
Main Classification O Financially Incapable/Incapacitated O O Urban Poor
Indigent Membership O Indigenous Peoples
to O Senior Citizen
Marginalized O Formal Labor and Migrant Workers
Sub Classification
Sector O Workers in Informal Sector
for Non Phil Health
O C1 O C2 O C3 (Check) O PWD
covered
admission/ O Victims of Disaster and Calamity
procedures O Others:
III. Monthly Expenses
Particulars Estimated Monthly Particulars Estimated Light Source Fuel Source Water Source (Check)
Cost (Php) Monthly Cost (Check and (Check)
(Php) state amount)
O Electric O Gas Artesian Well
House & Lot Communication

Food & Water House Help O Public

O Kerosene O Firewood
Education Medical O Private
Expenses
O Water District
Clothing Others: Specify
O Candle O Charcoal
Transportation

TOTAL
 IV. Medical Data
Admitting Diagnosis Final Diagnosis

Duration of Problems/Symptoms Previous Treatment/Duration

Present Treatment Plan Health Accessibility Problem

SEVERITY INDEX DURAT ION INDEX COPING INDEX

1. No problem 1. More than f ive years 1. Outstanding
2. Low 2. One to five years 2. Above average
3. Moderate 3. Six months to one year 3. Adequate
4. High 4. One to six months 4. Somewhat inadequate
5. Very High 5. Two weeks to one month 5. Inadequate
6. Catastrophic 6. Less than two weeks 6. No coping skills
V. Health and Mental Health
Absence of adequate health
services 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Inaccessibility of Health
Services 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Absence of support services
needed to use health 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Absence of adequate Mental
Health services 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Inaccessibility of mental
health services 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Absence of support services
needed to use mental health
1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
services
Others specify 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
VI. Discrimination
(Check Items) 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Age, Ethnicity, Religion, Sex,
Sexual Orientation, Lifestyle,
Non-Citizen, Veteran Status,
Dependency Status, Disability 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Status, Marital Status, Others
Specify
VII. Safety
Violence or crime in
community 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Unsafe working condition 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Unsafe conditions in home 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Absence of adequate safety
1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
services
Natural disaster 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Human created disaster 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Others specify 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Type of Social Interaction Severity Index Duration Index Coping Index
Problem 1. No problem 1. More than f ive years 1. Outstanding
1. Power 8. Mixed 2. Low 2. One to five years 2. Above average
2. Ambivalence 9. Others 3. Moderate 3. Six months to one year 3. Adequate
3. Responsibility 4. High 4. One to six months 4. Somewhat inadequate
4. Dependency 5. Very High 5. Two weeks to one month 5. Inadequate
5. Loss 6. Catastrophic 6. Less than two weeks 6. No coping skills
6. Isolation
7. Victimization
VIII. Assessment of Social Functioning
1. Familial Roles
Parent 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Spouse 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Child 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Sibling 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Other Family Member 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Significant Others 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
2. Other Interpersonal Roles
Lover 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Friend 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Neighbor 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Member 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Others (Specify) 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
3. Occupational Roles 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Worker Paid Economy 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Worker-Home 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Worker Volunteer 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Student 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Others specify 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
4. Special Life Situation
Roles
Consumer 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Inpatient/Client 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Outpatient/Client 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
ER patient/Client 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Prisoner 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Immigrant - legal 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Immigrant - undocumented 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Immigrant - refugee 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Others (specify) 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
No Social Interaction
Problems
IX. Problems in the Environment Severity Index Duration Index
1. No problem 1. More than five years
2. Low 2. One to five years
3. Moderate 3. Six months to one year
4. High 4. One to six months
5. Very High 5. Two weeks to one month
6. Catastrophic 6. Less than two weeks

A. Economic Basic Needs Systems

1. Food and Nutrition
Lack of regular food supply 1 2 3 4 5 6 1 2 3 4 5 6
Nutritionally Inadequate food supply 1 2 3 4 5 6 1 2 3 4 5 6
Documented Malnutrition 1 2 3 4 5 6 1 2 3 4 5 6
Others (specify) 1 2 3 4 5 6 1 2 3 4 5 6
2. Shelter
Absence of Shelter 1 2 3 4 5 6 1 2 3 4 5 6
Substandard or inadequate shelter 1 2 3 4 5 6 1 2 3 4 5 6
Other (specify) 1 2 3 4 5 6 1 2 3 4 5 6
3. Employment
Unemployment, employment is not available
in the community 1 2 3 4 5 6 1 2 3 4 5 6
Under employment, adequate employment
not available in the community 1 2 3 4 5 6 1 2 3 4 5 6
Inappropriate employment, lack of
socially/legally acceptable employment in
the community 1 2 3 4 5 6 1 2 3 4 5 6
Others(specify) 1 2 3 4 5 6 1 2 3 4 5 6
4. Economic Resources
Insufficient community resources for basic
sustenance 1 2 3 4 5 6 1 2 3 4 5 6
Insufficient resources in the community to
provide for needed services beyond 1 2 3 4 5 6 1 2 3 4 5 6
Others specify 1 2 3 4 5 6 1 2 3 4 5 6
5. Transportation
No personal/public transportation to
job/needed services 1 2 3 4 5 6 1 2 3 4 5 6
Others (specify) 1 2 3 4 5 6 1 2 3 4 5 6
No Problems in Economic/Basic Needs 1 2 3 4 5 6 1 2 3 4 5 6
B. Affectional Support System
Absence of affectional support system 1 2 3 4 5 6 1 2 3 4 5 6
Support system inadequate to meet
affectional needs 1 2 3 4 5 6 1 2 3 4 5 6
Excessively involved support system 1 2 3 4 5 6 1 2 3 4 5 6
Others (specify) 1 2 3 4 5 6 1 2 3 4 5 6
Assessment Findings Recommended Interventions

Conforme: Prepared by:

Patient/Guardian Signature/Thumb Mark Medical Social Worker

Licensed No.: