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FAMILY ASSESSMENT

Father: _____________________ Religion: __________________


Last First M.I
Mother: _____________________ Religion: ___________________
Last First M.I
Address: ________________________ Length of residency:
_________
______________________________ Place of origin:
______________

I. Initial Data Base


FAMILY STRUCTURE
a. Composition and Demographic Data

Members of Position in Age Sex Status


Household relation to
the head

b. Type of family
Based on Structure
О Nuclear
О Extended
Based on Residence
О Patrilocal
О Matrilocal
О Bilocal
О Neolocal
Based on Descent
О Patrilineal
О Matrilineal
О Bilateral
Based on Authority
О Patriarchal
О Matriarchal
О Equaliotarian
О Matricentric
Based on Stages
О Beginning family
О Child-bearing family
О Family with School Age children
О Family with Pre-School children
О Family with Teenage and Young Adult
О Post parental family
О Aging family

FAMILY RELATION
Questions:
1. How well do you get along with one another?
2. Do you support each other when there are family problems?

3. Is there love and affection between each member?

4. Is there a family discussion about certain problems during free time?

5. Who decides for the family as a whole?

6. How does your parent discipline their children? Do children respect


their parents?

7. Is there any unresolved conflict in the family?

SOCIO-ECONOMIC AND CULTURAL CHARACTERISTICS

Members of Educational Occupation Place of Monthly


Household Attainment work Income

a. Ethnical and religious background

1. What region did you come from?

2. Do you belong to an ethnic group?

3. What religion do you belong to?


4. Describe any customs and beliefs:
Health:

Illness:

Death:

5. Describe any restrictions in your religion that your health care


provider should know.

b. Significant Others and Roles

1. To whom do you refer during family crisis?

2. How this person related to you?

c. Role of Family members in the community

Is there a family member in the family who is a member of any


organization? If yes, what is his/her position?

HOME AND ENVIRONMENT

Housing Materials and Sanitation Facilities

Part of the Description/ Ventilation Physical and


house observation And Lighting Environmental
Hazards
a. Porch О Good
О Poor

Note:

b. Living О Good
Room О Poor

Note:

c. Toilet О Good
О Poor

Note:
d. Bedroom О Good
О Poor

Note:

e. Kitchen and О Good


Dining О Poor
room
Note:

f. Laundry О Good
area О Poor

Note:

Water Supply
О NAWASA
О Deep Well

Garbage Disposal:

Communication and Transportation facilities:

Community and Social Condition


Questions:
1. What are your rest activity patterns? Your sleep patterns?

2. Does each and every one of you have regular exercise habits? If yes,
what kind?

3. What are your special weekend activities?


4. Any social activities?

5. How often do you travel out?

HEALTH STATUS OF THE FAMILY

Medical History

Members Past When Hospitali Communic Habits


of the illness zed or able or not
family not

**Is there any current illness of the members in the family?


_______________________

HEALTH STATUS OF THE HOUSEHOLD MEMBERS (5years


old and below)

Name Age Weight Malnourish Immunization


or not
BCG: __at birth __at school
entrance
DPT: __1st dose__2nd
dose__3rd dose
OPV: __1st dose__2nd
dose__3rd dose
Hepa B: __1st dose__2nd
dose__3rd dose
TT: __1st dose__2nd dose__3rd
dose _4th dose _5th dose
Others:
_______________________

BCG: __at birth __at school


entrance
DPT: __1st dose__2nd
dose__3rd dose
OPV: __1st dose__2nd
dose__3rd dose
Hepa B: __1st dose__2nd
dose__3rd dose
TT: __1st dose__2nd dose__3rd
dose _4th dose _5th dose
Others:
_______________________
BCG: __at birth __at school
entrance
DPT: __1st dose__2nd
dose__3rd dose
OPV: __1st dose__2nd
dose__3rd dose
Hepa B: __1st dose__2nd
dose__3rd dose
TT: __1st dose__2nd dose__3rd
dose _4th dose _5th dose
Others:
_______________________
BCG: __at birth __at school
entrance
DPT: __1st dose__2nd
dose__3rd dose
OPV: __1st dose__2nd
dose__3rd dose
Hepa B: __1st dose__2nd
dose__3rd dose
TT: __1st dose__2nd dose__3rd
dose _4th dose _5th dose
Others:
_______________________

NUTRITIONAL STATUS

1. Do you observe a well-balanced diet?

2. How many glasses of water do you drink every day?

3. Is there any member of the family who has faulty eating habits?
4. Do any of you have food allergies?

5. Is there any food prohibited in your religion?

6. Did any of you have an illness or condition that made you change
the amount or kind of food that you eat?

PRACTICES AND BELIEFS ON HEALTH PROMOTION AND


MAINTENANCE

1. To whom do you rely on for health care services and healing?

What do they do?

2. Where do you bring a sick member of your family?

3. Who decides when to bring the patient to the hospital?

4. Does the family utilize health community facilities? What kind and
why?

5. Do parents attend to children’s need when sick?


6. Any cultural health practices your family has been exposed to?

II. Family Health Task

a. Ability to recognize signs of health and development:

b. Ability to manage health and non-health crisis:

c. Ability to provide health care for members:

d. Ability to provide environment favorable to good health and


development:

e. Ability to make use of resources for health care:

III.DIAGNOSIS: Statement of Health Condition

A. HEALTH DEFICIT:

B. PHYSICAL AND ENVIRONMENT HAZARDS:


C. FORESEABLE CRISIS:

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