Mountain View College School of Nursing C.

Joint Monthly Income:

( )Below Php 2,000 ( )Php 3,000-Php 4,999 ( )Php 5,000-Php 10,000
FAMILY HEALTH ASSESSMENT FORM ( )Php 10,000-Php 15,000 ( )More than Php 15,000
D. Basic Expenditures:
Respondent _______________________________________Age__________Gender____________________ 1. Food daily: ( )Below Php 50 ( )Php 50-75 ( )More than 75
Family Stage__________________________________________ Relation to Head______________________ 2. Clothing: Number of times of buying in a year: ( )Once ( ) Twice ( )More than 4 times
I. Family Data: Family Structure, Characteristics & Dynamics 3. Housing: ( )Water ( )Electricity ( )Cellphone Others_____________
A. Head of the Family______________________________________________________Age___________ 4. Schooling ( )Public ( )Private
B. Name of Spouse_______________________________________________________ Age___________ 5. Others:_________________________________________________________________________
C. Address ____________________________________________________Tel No. __________________ E. Nutrition:
D. Educational Attainment: Husband ________________________________________________________ 1. Food Preferences: ( )Fish ( )Fruits/Vegetables ( )Meat ( )Mixed ( ) others _____________
Wife ____________________________________________________________ 2. Common Fare: (24 hours, or 6 weeks to 6 months food recall): ( )Rice & egg ( )Rice & sardines
E. Length of residency_______________________________________________________ ____________ ( )Rice & Noodles ( )Others__________________________________________
F. Ethnic Origin: Husband ______________________ Wife_______________________________________ F. Nutritional status of children below 12 years old:
G. Family Type:( )Patriarchal ( )Matriarchal ( )Nuclear ( ) Extended ( )Others (specify)__________________ Name Date of Birth Weight Height Nutritional Status
H. Number of Children______________________________________
I. Dominant family members in terms of decision making, especially in matters of health care: ____________
_____________________________________________________________________________________
J. General family relationships/Dynamics:
a. Presence of any obvious/readily observable conflict between members ______________________
______________________________________________________________________________ III. Housing and Environmental Conditions
b. Characteristics communication/interaction patterns among members _______________________ A. Home:
______________________________________________________________________________ 1. Living Space (measurement)____________________________________________________________
K. Members of the household: 2. Sleeping arrangement_________________________________________________________________
Name Relation to Age Gender Civil Educational Level Occupation
Head Status
3. Presence of breeding or resting of insects, rodents or other vectors_____________________________
4. Presence of accident hazards
( )Beside the highway ( )Under the coconut trees ( )Stairs no handrails
( ) Children (1-10 years old) left alone in the house ( ) Others ( Specify_____________________
5. Cooking facilities: ( ) Electric ( )Gas Stove ( ) Butane ( )Earthen ( ) Others__________
6. Type of Housing: ( )Concrete ( )Wood ( )Makeshift ( )Mixed[describe]___________
7. Ownership: ( )Owned ( )Rented ( )Rent free ( )Others_____________
8. No. of Rooms for Sleeping: _______
II. Socio-economic Data & Cultural characteristics 9. Ventilation: ( )Good ( )Poor
Occupation Place of Work Income Adequacy to meet 10. Lighting Facilities: ( )Electricity ( )Kerosene ( )Chargeable Light ( )Others________
Basic necessities 11. Toilet facility: ( )Type ( )Pit Privy ( ) Antipolo ( ) bore hole latrine ( )Water sealed
Father: Yes:______ No ____ Ownership____________Sanitary Condition____________
Mother: Yes ______ No ____ 12. Drainage system Type: ( )Open ( )Closed ( )No Drainage
1.Who makes decision about money and how it is spent? ________ 13. Garbage Disposal Type: ( )burning ( )Compost pit ( )open ( )Sanitary condition
2. Significant other/s___________________ Roles they play in family life: (a. ) (b.) ( )Others _______________________________________________________
3. Relationships of the family to larger community: 14. Presence of Animals __________________________________________________________________
A. Source of income:__________________________________________________________________ 15. Backyard Gardening ( )Vegetables ( ) Herbal ( ) fruit trees ( )Others___________________________
B. Occupation: Husband: ( )Employed ( )Unemployed ( )Self employed ____________________ 14. General Surroundings: ( )Clean ( )Dirty Sanitary Observations_________________________________
Wife: ( )Employed ( )Unemployed ( )Self employed ____________________
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 15. Water Supply: ( )Artesian ( )Deep Well ( )NAWASA ( )Others________________________________ 5.
16. Storage of Drinking Water: ( )Refrigerated ( )Covered ( )Uncovered ( )Others _____________________ Hospitalized?
17. Food Storage : ( )Covered ( )Uncovered ( ) Others__________________________________________ Dx-
Where hospitalized?
E. Community Observation: Not hospitalized
1. Kind of neighborhood: ( )slum area ( )rural ( )urban ( ) congested _________________
2. Sanitary condition:________________________________________________ 2. |Beliefs and Practices related to health and illness
3. Presence of breeding sites of vectors/insects:____________________________ a._________________________________________________________________________________
4. Health Facilities :__________________________________________________ b._________________________________________________________________________________
5. Distance of House to nearest Health Facilty______________________________
6. Social Facilities____________________________________________________ c._________________________________________________________________________________
7. Recreational Facilities:______________________________________________ 3. Nutritional assessment (especially for vulnerable or at-risk members)
8. Communication Facilities____________________________________________ a. Anthropometrics data (children): Weight in kgs. Height in ft. & inches
9. Transportation Facilities_____________________________________________ Upper arm circumference_____________ _______________ _________________
IV. Health Status/ condition b. Dietary history indicating quality and quantity or food intake per day (usual food) eaten for
1. Status of Each Family Member: past few weeks)or 24 hour food recall.
Medical History & Hereditary Past Illnesses Medications Taken/Treatment _____________________________________________________
Diseases Done _____________________________________________________
Father Hospitalized?
Dx- c. Eating/feeding habits/practices:
Where hospitalized? between meals ___ junk foods ___amount of water intake per day _______
Not hospitalized ____________________________________________________________
_________________ 4. Physical assessment indicating presence illness states (diagnosed or undiagnosed by medical
Mother Hospitalized? practitioner___________________________________________________
Dx- ___________________________________________________________________
Where hospitalized? 5. Laboratory/diagnostic results____________________________________________
Not hospitalized ___________________________________________________________________
_________________ V. Values, Practices of Health Promotion/Maintenance and Disease Prevention
Children Hospitalized?
1. 1. Use of preventive health services
Dx- a. Immunizations__________ ___________ ____________ __________ ______________
Where hospitalized?
b. Exercises _________________________________________________________________
Not hospitalized
_________________ c. Proper diet__________________________________________________________________
2. Hospitalized? d. Stress management ()anger ()sleep ()escape ()inflicting pain () talk ()others
Dx- e. Smoking: yes_______ no ______ how many ___________
Where hospitalized? f. Drugs: yes ______ no ______ what kind ___________
Not hospitalized g. Alcoholic drinks: yes ________ no ____________
_________________ h. Sleep and rest: what kind-
3. Hospitalized? Nap after lunch: yes _________ no ________Number of hours of sleep - __________
Dx-
Where hospitalized? FAMILY HEALTH PROBLEMS (Identified WITH family member/s)
Not hospitalized Cues Health Problems Family Nursing Problem
_________________
4. Hospitalized?
Dx-
Where hospitalized?
Not hospitalized
_________________