B.

Type of Family Form:

C. Cultural and Religious Orientation

D. Social Class Status: 1. Breadwinner: 2. Average Monthly Family Income: E. Recreational or Leisure time activities:

II.

PHYSICAL ENVIRONMENT A. Home 1. Ownership: House: ( ) Owned ( ) Rental ( ) Rent-Free ( ) Others Lot: ( ) Owned ( ) Rental ( ) Rent-Free ( ) Others 2. Construction materials used: ( ) Light ( ) Mixed ( ) Strong 3. Number of rooms used for sleeping: 4. Specific room for ( ) kitchen and ( ) dining. 5. Furniture: ( ) None ( ) Limited ( ) Adequate 6. Home appliances present: 7. Lighting facilities: ( ) Electricity ( ) Kerosene ( ) Others, specify ( ) loose rickety stairs ( ) loose doors, walls, posts windows: ( ) none, ( ) only 1, ( ) more than 1 sharps and matches within reach of children? Yes/No softdrink bottles used as kerosene containers? Yes/No medicines and poisonous substance kept side by side? Yes/No ( ) electric stove ( ) Firewood/charcoal ( ) Open drainage ( ) Gas stove

8. Safety hazards:

B. Kitchen 1. Cooking Facility: 2. Sanitary condition drainage facility:

( ) Closed Drainage

C. Water Supply Please indicate water source by placing a check mark (/) in the appropriate column SOURCE PUBLIC PRIVATE 1.Natural Spring 2.Electric water pump 3.Open well (tabay) 4.Piped system 5.Artesian well(bomba) 1. Distance from the house: (m) 2. Collection containers: CONTAINER a.bottles b.cans c.pails d.others (specify) 2. Storage CONTAINER a.Jar (banga) w/ faucet b.Jar (banga) w/o faucet c.Can d.Pitcher e.Pail f.Others WITH COVER WITHOUT COVER WITH COVER WITHOUT COVER

D. Waste Disposal 1. Toilet a. Type: TYPE Open pit privy Bored-hole latrine Antipolo system Pail system Closed pit privy Overhung latrine Flush type Water sealed Other (specify) b. Distance from the house: (m) OWNED SHARED

c. Sanitary conditons (describe)

2. Refuse and Garbage a. Container CONTAINER a.Plastic b.Sack c.Can d.Steel drum e.Others ( ) No container used

WITH COVER

WITHOUT COVER

b. Method of disposal ( ) hog feeding ( ) open dumping ( ) buming ( ) buried in pit ( ) composting ( ) motorized collection system ( ) others, specify E. Domestic animals KIND NUMBER WHERE KEPT

F. The Community in General 1. Type of community: RESIDENTIAL AREA Rural Urban Suburban 2. Accessible to: (encircle) a. Transportation b. Church c. School d. Market e. Shopping center f. Health agency 3. 4. 5. 6. INDUSTRIAL AREA

YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO

Congested neighborhood: YES/NO Recreational facilities present: Health care facilities present: Distance of the house to the nearest health care facility: (m)

7. Family perception of this community 8. Family associations and transactions with the community: a. What community services are usually utilized by the family? b. Who in the family uses these community services? c. Frequency of community serviceutilization? d. Familys perception of the agency from whom it receives assistance

III. PSYCHO-SOCIAL ENVIRONMENT A. Family Strengths and Weaknesses: Strengths Weaknesses

B. Family Communication 1. Usual patterns 2. Purposes:

( ) wheel ( ) isolate ( ) chain ( ) switchboard

3. Rules observed during interactions:

C. Family Stage of Development 1. Present Stage:

2. Developmental task demonstrated by the family at the present stage:

D. Role Structure FAMILY MEMBER

FORMAL ROLE

INFORMAL ROLE

E. Power Structure Decisions to be made 1. Major family purchases 2. Daily household expenses 3. Child-rearing practices 4. Social activities 5. Household activities 6. Discipline 7. Health-illness matters

Decision maker

Decision-making process

) Over-all family Power typology ( ) chaotic (leaderless) family ( ) egalitarian (shared power) family ( ) syncretic (mutual commitment) ( ) atomistic (automatic or independent commitment) ( ) autocratic ( ) husband-dominated family ( ) wife-dominated family F. Family Values 1. Identified and practiced moral values.

2. How do these family values affect the health status of the family?

G. Family Coping Functions 1. Short-term stressors

2. Long-term stressors

3. Family strengths which counterbalance stressors

4. Functional coping strategies utilized by the family (past & present

IV. HEALTH-RELATED BEHAVIORS I.Family attitude towards: 1. health: 2. illness: II. Health care facilities: 1.usual source of health care 2. frequency of visit to health care facility 3. member of family who usually utilizes health care services: 4. means of financing health care 5. barriers to obtaining health care III. Dental Health Practices

IV. Family Medical History

V. Family Drug Habits

VI. Nutrition 1. Dietary practices and food allergies 2. Food history record

SAMPLE MENU FOR ONE DAY MEAL FOOD SERVED QUANTITY INDIVIDUAL DIFFERENCES

3. Market practices

VII. Sleep and Rest Practices FAMILY MEMBER TIME FOR SLEEPING TIME FOR WAKING SLEEPING AIDS USED

V. FURTHER ASSESSMENT DATA NEEDED:

Interviewer:

FAMILY HEALTH ASSESSMENT Head of the Family: Address (include important landmarks): Date:

I.Assessment of the Family A. Members of the Household NAM E Relatio n to Head se x Birth Date Mont h Yea r Ag e Marit al Status Highest Educatio n Occupati on Type of Work Plac e Immunizati on Status Physic al Health

B. Type of Family Form:

C. Cultural and Religious Orientation