D: Social Class Status: d.

others (specify)
1. Breadwinner:
2. Average Monthly Family Income: 3. Storage
E: Recreational or Leisure Time Activities:

II. PHYSICAL ENVIRONMENT

A. Home
1. Ownership CONTAINER WITH COVER WITHOUT COVER
House: ( ) Owned ( ) Rental ( ) Rent – Free () a. jar (banga) with
Others faucet
Lot: ( ) Owned ( ) Rental ( ) Rent – Free () b. jar (banga)
Others without faucet
2. Construction materials used for Housing: ( ) Light () c. can
Mixed ( ) Strong d. pitcher
3. Number of rooms used for sleeping: e. pail
4. Specific room for ( ) kitchen ( ) dining f. others
5. Furniture: ( ) None ( ) Limited ( )Adequate
6. Home appliances present: D. Waste Disposal
7. Lighting facilities: ( ) Electricity ( ) Kerosene 1. Toilet
( ) Others, specify a. Type
B. Kitchen
1. Cooking Facility: ( ) Electric Stove ( ) Gas Stove ( ) TYPE OWNED SHARED
Firewood/Charcoal Open Pit Privy
2. Sanitary Condition Bored Hole Latrine
Drainage Facility: ( ) Open Drainage ( ) Closed Antipolo System
Drainage Closed Pit Privy
C. Water Supply Overhung Latrine
Flush Type
SOURCE PUBLIC PRIVATE Water Sealed
1. Natural Spring Others (Specify)
2. Electric Water b. Distance from the house: (m)
Pump c. Sanitary Conditions (describe)
3. Open Well
(Tabay) 2. Refuse and Garbage
4. Piped System a. Container
5. Artesian Well
(Bomba) SOURCE WITHCOVER WITHOUT COVER
Plastic
1. Distance from the house: (m) Can
2. Collection containers: Sack
Steel Drum
SOURCE WITHCOVER WITHOUT COVER Others (describe)
a. bottles ( ) No containers used
b. cans b. Method of Disposal
c. pails ( ) hog feeding ( ) open dumping ( ) burning
 ( ) buried in pit ( ) composing ( ) motorized d. Family’s perception of the agency from whom it receives
collection system assistance
( ) Others, specify

III. PSYCHOSOCIAL ENVIRONMENT

B: Family Strength and Weaknesses
Strength

Weakness
E: Domestic Animals

KIND NUMBER WHERE KEPT C: Family Communication

1. Usual Patterns: ( ) Wheel ( ) Isolate
( ) Chain ( ) Switchboard
F: The Community in General 2.Purposes
1. Type of Community
3.Rules observed during interactions:
TYPE Of RESIDENTIAL INDUSTRIAL
COMMUNITY AREA AREA D:Family Stage or Development
Rural 1. Present Stage:
Urban
2. Developmental task demonstrated by the family at the
Suburban
present stage:
2. Accessible to: (encircle) E:Family Values
a. Transportation YES/NO
b. Church YES/NO 1. Identified and practiced moral values
c. School YES/NO
d. Market YES/NO 2. How do these family value affect the health status of the
e. Shopping center YES/NO family
f. Health agency YES/NO
3. Congested Neighborhood: YES/NO
4. Recreational Facilities present: G:Family Coping Functions
5. Health Care Facilities present:
6. Distance of house to the nearest Health Care Facilities: 1.Short – term stressors
7. Family’s Perception of this community
8. Family’s Association and transactions with the community: 2. Long – term stressors
a. What community services are usually utilized by the
family 3. Family strength which counterbalances stressors

b. Who in the family uses these community services? 4. functional coping strategies utilized by the family

IV: HEALTH RELATED BEHAVIORS

c. Frequency of community service utilization
A. Family attitude towards:
1. Health
 2. Illness

B: Health Care Facilities

1. Usual source of health care
2. Frequency of visit to health care facility
3. Members of family who usually utilized health care
services
4. Mean of financing health care
5. Barriers to obtaining health care
C: Dental Health Practices

D: Family Medical History

E: Family Drug Habits

F: Nutrition
1. Dietary practice and food allergies

2. Food history record

SAMPLE MENU FOR ONE DAY

MEAL FOOD SERVED QUANTI INDIVIDUAL
TY DIFFERENCES

3. Market Practices:

G:Sleep and Rest Practices

Family Time for Time Sleeping aids used (if

Membe Sleeping for any)
r Waking