Mapandi Memorial College

048 Buanda BLLVD,Lilod,Saduc, Marawi City

FAMILY HEALTH ASSESSMENT

Name of the Brgy: ______________________

Household Number: ______________________
Date of Assessment: ______________________
Respondent: ______________________
Interviewer: ______________________

I. Family Data
A. Father

Name: ____________________________ B-date: _____ Age: __________

Occupation: __________________ Educational Attainment: _______________________
Does he have any possible disorder? ( ) No ( ), If yes, what? _________________________
Does he smoke? Yes ( ) No ( ), If yes, how many sticks a day? _____________________
Does he drink alcohol? If yes, how many bottles/glasses a day ______________________

B. Mother

Name: ____________________________ B-date: _____ Age: __________

Occupation: __________________ Educational Attainment: _______________________
Does he have any possible disorder? ( ) No ( ), If yes, what? ________________________
Does he smoke? Yes ( ) No ( ), If yes, how many sticks a day? _____________________
Does he drink alcohol? Yes ( ) No ( ), If yes. how many bottles/glasses a day _________
G__________T___________P___________A___________L__________D__________
Tetanus Toxoid/Tetanus Diphtheria Status: __________________________________
Is she pregnant? Yes ( ) No ( ), If yes, fill in the following:
1. Last Menstrual Period: _______________________________
2. Expected date of confinement: __________________________
3. Age of Gestation by weeks (during assessment): _______________________
Is she a postpartum (24hrs- 10 days after delivery) mother? Yes ( ) No ( ), If yes fill in the
following:
1. How many days? _________________________________
2. Any danger sign present? ______________________________
3. Had she given iron (with folic acid), If yes how many tabs were given? _____________
4. Had she given vitamin A, Yes ( ) No ( ).
5. Is she Exclusive Breastfeeding? YES ( ) NO ( ), If no formula used: _____________
6. Does the baby referred to Newborn Screening? If yes, when? ____________________
C. Adress: ______________________________________________________________
 D. Contact #: ____________________________
E. Length of Residency: _________________________
F. Ethnic Origin: ___________________________
G. Religion: _____________________________
H. TYPE OF FAMILY:
1. Nuclear ______________ 2. Extended _______________

I. NUMBER OF LIVING CHILDREN: ___________

Name of Gender Birthdate Age Educational Occupation Relationship

children attainment

Other members Gender Birthdate Age Educational Occupation Relationship

family attainment

J. Any possible disorder present in the children or other members of the family?

NAME: Possible disorder:

1.

2.

3.

II. Socio- economic Data

A. Source of income
1. Employed _____ 2. Unemployed _____ 3. Self- Employed
B. Monthly income
1. 1000 ____ 2. P2000- P3000 ____ 3. P3000-P4000 ____ 4. P5000 and above ____
C. Housing
1. Water: ____ 2. Electricity: _____ 3. Computer/WIFI: _____ Others(specify): _____
D. Schooling
1. No. of children in public school: _____ 2. No. of children in private school: _____
3. No. of children in Madrasah: _____
III.Housing and Environment Condition
A. Type of housing
1. Concrete ____ 2. Wood ____ 3. Mixed ____ 4. Others (Specify) _____
Is this house
Owned? ______ Shared: _______ Others:(Specify) ________
B. Ventilation
1. Good ____ 2. Poor _____
C. Lighting
1. Adequate ____ 2. Inadequate ______
D. Surroundings
1. Clean ____ 2. Dirty _____ 3. Others (specify): _____
E. Source of water supply
1. Well____ 2. Deep well _____ 3. Spring ____ 4. River ____ 5. Others(specify) ____
F. Storage of drinking water
1. Refrigerated: _____ 2. Covered: _____ 3. Uncovered: ______
G. Containers used for drinking water
1. Plastic: _____ 2. Bottles: _____ 3 Jars: ______ 4. All: ______
H. Toilet facilities
1. Flush type: _____ 2. Pit privy: _____ 3 “Ballot system”: ______
4. Water sealed: _____ 5. Others (specify): _____
I. Ownership of toilet facilities:
1. Owned: _____ 2. Shared with HH: _____ 3. Shared with community: _____
J. Garbage disposal
1. Collection: _____ 2. Burying: _____ 3. Burning: _____ 4. Open dumpling: ____
5. Others (Specify): _____
k. Food storage
1. Covered: _____ 2. Refrigerator: _____ 3. Uncovered: _____
L. Presence of Animal (Specify) ____________________________________________
M. Backyard gardening
1. Vegetables: _____ 2. Herbal: _____ 3. Fruit bearing: _____ 4. Others (Specify):___
IV. Community Resources
1. Health center ______________
2. Mosque _______________
3. School _______________
4. Market ________________
5. Park ___________________
6. Brgy. Hall ________________
7. Basketball court ____________________
8. Madrasah ________________
A. Indigenous health workers
1. Trained hilot _____ 2. Untrained hilot _____ 3. Herbularyo _____
B. Primary health care team
1. Doctor _____ 2. Nurse _____ 3. Midwife _____ 4. BHW _____
V. Nutriton
A. Food Preference
1. Fish _____ 2. Mear _____ 3. Fruits ____ 4. Vegetables ____ 5. Mixed _____
B. Presence of nutritional deficiencies
1. Goiters
a. Enlargement of the neck __________________
b. Hoarseness __________________________
c. Dysphagia ________________________
d. All __________________________
2. Anemia
a. Pallor ________________
b. Body weakness ___________________
c. Easy fatigability _________________
d. All ____________
3. Vitamin A deficiency
a. Night blindness _______________
b. “pilak sa mata” ________________
c. Others _____________
VI. Knowledge, Attitude and Practice
A. Do you utilize the health care?
1. Yes ____ 2. No _____
B. Reasons
1. Illness ____ 2. FP ____ 3. Dental _____ 4. Prenatal _____ 5. Postnatal _____
6. Nutrition _____ 7. Immunization _____ 8. Consultation _____
C. First person consulted in times of illness
1. Doctor ____ 2. Nurse ____ 3. Midwife _____ 4. Hilot _____ 5. BHW _____
6. Herbularyo _____7. Others (Specify) _____
D. Usual illness of the family
___________________________________________________________________
E. What do you do to this condition?
1. Self – medication? _____ 2. Consultation _____ 3. Hospitalization _____
4. Private clinics _____ 5. Others (Specify) _____
F. Familial diseases: _________________________________________________