FAMILY HEALTH RECORD

I. PERSONAL HOUSEHOLD DATA

A. Head of the Family

Name: Leopoldo Noche Age: 72 Date of Birth: September 12, 1947

Civil Status: Single Religion: Roman Catholic Occupation: Unemployed
Educational Attainment: Elementary level Income: ~1000/month previously

B. Members
Relation Date of Civil Educ.
Name Age Occupation Residence
to Head Birth Status Attainment
-
-
-
NONE
II. HOUSEHOLD ECONOMIC STATUS
A. Gross Household Income (cumulative contributed household income):
< 1,000/mo X 1,001-3,000/mo 3,001-5,000/mo 5,001-10,000/mo
10,001-15,000/mo 15,001-20,000/mo 20,001-25,000/mo >25,000/mo
B. Source(s):
X Agriculture Employment Business Others (pls specify) ________________

III. HOUSE & LOT OWNERSHIP and ENVIRONMENTAL SANITATION

A. Housing
Rented X Owned Shared No of Rooms: 1
Concrete Light X Mixed X Habitable Non-habitable
B. Water Supply
1. Source
Local Water System (e.g. MIWD) River X Pump well Spring Bottled water

X Artesian well Rain water Others (pls specify) ________________________

2. Distance of water source from potential source of pollution
X ≤ 50 ft > 50ft Pollution Source (type & location): Sewage
3. Methods for water transport to residence
In-door faucet Pump Barrel X Pail Water can
Others (pls specify) __________________ With cover X Without cover
4. Storage
X Water tank X Jar Others (pls specify) ________________________________
X With cover Without cover X With faucet Without faucet
5. Methods of making water safe for drinking
Boiling Chlorination Filtration X None
Others (pls specify): Purified Water
6. Use of drinking glasses
Individual X Common (no individual glass)

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Family Health Record, 2011 Family & Community Medicine, College of Medicine, WVSU

C. Toilet Facilities
1. Type of toilet
Flush-type with septic tank X Water-sealed (pour-flush) Pit privy (Antipolo type)
Others (pls specify) ________________________________________________________________________
2. Cleanliness
Good X Fair Poor
D. Garbage Disposal
Burned Buried Fed to animals Dumped in isolated areas
Open pit Scattered Composting X City/Municipal/Community garbage collection
Others (pls specify) ________________________________________________________________________
E. Premises
1. General condition
Very clean X Fair Needs cleaning
2. Sewage drainage
X Blind (covered, buried) Open drainage None
3. Insect vector breeding places
Fly-breeding places only Mosquito-breeding places only X Both fly & mosquito breeding places
4. Domestic animals (pls state number) NOT ALLOWED
Dog _____0_____ Cat _____1_____ Pig _________ Chicken ____~20_____ Duck _____0____
Others (pls specify & state number) ______________________________________________________________

IV. MATERNAL and CHILD HEALTH

Family Planning methods used (pls check all that apply)
X None Withdrawal Rhythm Condom Pills Skin Patch
IUD Diaphragm Male Sterilization Female Sterilization Contraceptive Injection
Name of child Place of delivery Complications Immunizations
-
- N/A
V. CHILD NUTRITION
Type of feeding Nutritional status Usual food
Name of child Age Date weaned
(weight for age) served to child

N/A
VI. FAMILY HYGIENE and PRACTICES
A. Family Hygiene
X Bathing X Brushing of teeth Washing before sleeping
X Washing hands before eating X Washing hands after using the toilet
B. Eating Habits
X Eating utensils X Serving spoons Leftover food Eat raw food
C. Food Storage
X Screened cupboards Open cupboards Refrigerator
Others (pls specify) ____________________________________________________________________________

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Family Health Record, 2011 Family & Community Medicine, College of Medicine, WVSU

FAMILY APGAR QUESTIONNAIRE PART I

Almost Some of the
Hardly Ever
Always Time
I am satisfied that I can turn to my family for help when
A X
something is troubling me.
I am satisfied with the way my family talks about things with
P X
me and shares problems with me.
I am satisfied that my family accepts and supports my wishes
G X
to take on new activities or directions.
I am satisfied with the way my family expresses affection and
A X
responds to my emotions such as anger, sorrow and love.
I am satisfied with the way my family and I share time
R X
together

Total: 4/10

FAMILY APGAR QUESTIONNAIRE PART II

Who lives in your home? How do you get along?
Relationship Age Gender Well Fairly Poor

NONE N/A
If you don’t live with your own family, list the persons
to whom you turn for help How do you get along?
Relationship Age Gender Well Fairly Poor
Annie 70s F X
Marilou 70s F X

SCREEM
Problems Identified Resources Solutions
Ignoring gossips
Gossip from neighbors Reach out to other family
Family
Social No immediate family members members
Friends
nearby Establish a good relationship with
friends and family mebers
Cultural None None None
Religious None None None
Employment, 4Ps, small business
Economic Small income Budgeting and savings
with nearby relatives
Can read and write but with Friends May ask help from friends
Educational
difficulty Social worker May enrol in ALS
Distance from the nearest
Seek consult even when not sick
Medical hospitals/health centers BHW
Contact the BHW
Poor health seeking behavior

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Family Health Record, 2011 Family & Community Medicine, College of Medicine, WVSU

FAMILY ASSESSMENT TOOLS

GENOGRAM
Noche Family
Miagao, Iloilo
April 4, 2018

II Filimon Dominga
73 72

III
Lolita Leopoldo Jr
50 72 65

LEGEND
- PTB
- Leprosy

FAMILY TYPOLOGY

o Family Coherence VS Family Hardiness

Vulnerable Family (Low in Coherence and Low in Hardiness)

- Vulnerable families are complacent, less likely to try new and exciting things, tending to do the same
things over and over, and are less likely to encourage each other to be active and to learn new things
things

o Family Time and Routines VS Valuing Family Time and Routines

Unpatterned Family (Low in Valuing Family Time and Routine but Low in Family Time and Routine)

- Unpatterned families neither value routines nor implement family routines.

o Flexibility VS Family Bonding

Fragile Family (Low in Flexibility and Low in Bonding)

- Fragile families lack emotional bonding between members and are unable to deal with stress in a
flexible, participatory way

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FAMILY CIRCLE TECHNIQUE ECOMAP

Marilou
Filimon Dominga
73 72
Marilou

Annie
Annie
Leopoldo Leopoldo Jr
72 65

Friends
Friends
Relatives

Education

Community

Economy/
Finances

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Family Health Record, 2011 Family & Community Medicine, College of Medicine, WVSU

MINUCHIN

Filimon Dominga
73 72

Leopoldo Jr
72 65

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