Family Health Record

Head of the Family : _______________________________ Family No. :____________

Address : _______________________________ Zone :
____________
Date : _______________________________

I. Assessment of the Family, Home & Environmental Conditions:

A. Family Type:
( ) Nuclear ( ) Extended ( ) Matriarchal ( )
Patriarchal
B. Members of the Household:

Family Member Relatio Se Ag Birthday Marita Religio Highest Occupation

# Name n to x e M D Y l n Educatio Type Place Income
Head Status n of
Complet Work
ed

C. General Family Relationship/Dynamics:

Criteria Status Additional

Information

D. Home & Environment

1. Home
a. Ownership: ( ) Owned ( ) Rented ( ) Rent-free
b. Construction materials used:
( ) Light ( ) Mixed ( ) Strong
c. No. of rooms used for sleeping:__________
d. Lighting Facilities:
( ) Electricity ( ) Kerosene ( ) others:
Specify_______
e. Appliances owned:
____________________________________________
f. General Sanitary Condition;
_____________________________________
Common household pests found at
home______________________
Are there breeding sites of insects/rodents, etc. present?
( ) Yes ( ) none

2. Drinking Water Supply

( ) Private ( ) Public
a. Source: ( ) Pump well ( ) Deep well ( ) NAWASA
( ) Distilled/Purified
b. Distance from house:___________________
 c. Storage:
( ) None (direct from faucet or pipe)
( ) Large covered container with faucet
( ) Large uncovered container with faucet
( ) Others, specify:___________________

3. Kitchen
a. Type of food:
Breakfast:
( ) Meat & Rice ( ) Mixed
( ) Vegetable & Rice ( ) Processed food
with Rice
( ) Others:______

Lunch:
( ) Meat & Rice ( ) Mixed
( ) Vegetable & Rice ( ) Processed food
with Rice
( ) Others:______

Supper:

( ) Meat & Rice ( ) Mixed

( ) Vegetable & Rice ( ) Processed food
with Rice
( ) Others:______
b. Cooking Facility:
( ) Electric Stove ( ) Firewood
( ) Gas stove ( ) Charcoal
c. Food Storage:
( ) Refrigerator ( ) Kitchen ware
( ) Pots/Pans ( ) Cabinet
d. Sanitary Condition:______________________________
e. Drainage Facility:
( ) Open Drainage
( ) Blind Drainage
( ) None
4. Waste Disposal

a. Refuse & Garbage

Container ( ) Covered ( ) open ( ) None
Method of Disposal
( ) Hog feeding ( ) Open Burning
( ) Open Dumping ( ) Garbage Collection
( ) Burial in pit ( ) Composting
( ) others:____________________
b. Toilet
Type ( ) None ( ) Pail system
( ) Over hung latrine ( ) Antipolo
( ) Open pit privy ( ) Water-sealed Latrine
( ) Close pit privy ( ) Flush type
( ) Bored-hole latrine ( )
others:________________
Distance from house:_____________________
Sanitary condition:_______________________

5. Domestic Animals

Kind Number Where kept

 E. The Community in General

a. General Sanitary
condition:_________________________________________
b. Housing Congestion: ( ) yes ( ) No
c. Are there Accident hazards present? ( ) Yes ( ) None
c. Availability of Health Care Services (Describe briefly)
______________________________________________
d. Distance of house from nearest health center facilities
______________________________________________
e. Nearest Government Hospital
______________________________________________
f. Nearest Recreational Park:
______________________________________________
g. Nearest Public School:
______________________________________________

II. Health Assessment and Status

A. Family Health Status/Health History
( ) Diabetes Mellitus ( ) Tuberculosis
( ) Hypertension ( ) Hepatitis
( ) Cancer ( ) Human Immunodeficiency Virus
( ) Asthma ( ) Cardiovascular Disease
( ) Cerebrovascular ( ) Malnourished
Accidents ( ) Others:_____________________________
B. Lifestyle
( ) Sedentary
( ) Alcohol Drinker
( ) Smoker
C. Accidents:

Household Name of Accident When Where Remarks

Member

D. Health & Health Practices

a. To whom you consult for health related problems?

( ) Manghihilot ( ) Albularyo ( )
Others:__________
( ) Midwife ( ) Nurse
( ) Doctor ( ) Health Center
b. for problems other than health, whom do you consult?
( ) family members ( ) relatives ( )
others:__________
( ) friends ( ) Barangay Officials
E. Childhood Immunization:
Name of Age BCG Hepa B DPT OPV Measles Others
Child

F. Pregnancy Profile:

1. Baseline Data

HHM# Age Blood Weight LMP EDC AOG Gravida Para

Pressure

2. Immunization
HHM# TT1 TT2 TT3 TT4 TT5

3. Common Pregnancy Discomforts:

( ) Nasal Stuffiness
( ) Nausea/vomiting
( ) Feeling Faint
( ) Frequent Urination
( ) Increase Vaginal Discharge
( ) Shortness of Breath
( ) Heartburn
( ) Backache
( ) Constipation & Hemorrhoids
( ) Trouble sleeping

4. Common Danger Signs:

( ) Fever ( ) Sudden weight gain
( ) severe vomiting ( ) Edema on hands & face
( ) Headache ( ) Sudden gush of fluid
( ) Blurred vision
( ) pain in Epigastric region
5. Family Planning: ( ) Natural ( ) Artificial ( ) None

HHM# Withdrawa Rhythm Abstinenc Pills Depo Condom IUD

l Method e Provera
 6. Suggested Topics for Health Education:

( ) Family Planning ( ) Tuberculosis

( ) Dengue Prevention ( ) Malaria
( ) Proper Garbage Disposal ( ) Diarrhea
( ) Malaria ( ) Cholera
( ) Rabies

III. Awareness of Community Organization:

A. Are you aware of existing organizations in the community?

( ) Yes ( ) No
B. Name all organizations you know:

No Name of Organization
.

C. Are you a member of any of these organizations?

( ) Yes ( ) No
D. Are you aware of its activities and projects?
( ) Yes ( ) No
E. How are you involved in its activities?
( ) attend meetings ( ) give donations
( ) planning ( ) Evaluation
( ) implementation ( ) Others:__________
F. Name 5 formal and non formal leaders of the community whom you think
can lead the people.

No. Name of formal/non formal

Assessed by:

_____________________________
Signature over printed name

Checked by:

_______________________________
signature over printed name

COMMUNITY FAMILY DIRECTORY

Assigned Head of the House Zone Birthday
Househol Family Number
d
Number
HOUSEHOLD FAMILY DIRECTORY
Head of the Family : Zone :
Household Number : Date :

Household Member Members of the Family Birthday

No.

HOUSEHOLD FAMILY DIRECTORY

Head of the Family : Zone :

Household Number : Date :

Household Member Members of the Family Birthday

No.
 PREGNANCY WATCH

Household Name Last Menstrual Age of Expected Date

Number Period Gestation of Delivery
 BLOOD PRESSURE MONITORING
Date Name of Age Blood Signature Remarks
Client Pressure
 SERVICE & PROGRESS NOTE

Name of Client : Assigned

Household No.:
Zone :

DATE HEALTH NURSING SIGNATURE

CONDITIONS/ OBSERVATIONS,
NURSING ACTIONS
PROBLEMS TAKEN/PROGRESS/OUTC
OME

SERVICE & PROGRESS NOTE

Name of Client : Assigned
Household No.:
Zone :

DATE HEALTH NURSING SIGNATURE

CONDITIONS/ OBSERVATIONS,
NURSING ACTIONS
PROBLEMS TAKEN/PROGRESS/OUTC
OME

RELATED LEARNING EXPERIENCE

ATTENDANCE

Group : Date :
Area : Clinical Instructor:

Name Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Rema

rks

________________________________
Signature of Clinical
Instructor
 RELATED LEARNING EXPERIENCE
ATTENDANCE

Group : Date :
Area : Clinical Instructor:

Name Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Remar

ks

________________________________
Signature of Clinical
Instructor