College of the Holy Spirit of Manila

COLLEGE OF NURSING
163 E. Mendiola St., Manila
Telefax: (02) 734. 7921

FAMILY ASSESSMENT GUIDE

Family Name: ___________________________________________________________

Address: _______________________________________________________________

I. Demographic Data

Household No. _________ Barangay House No. __________

II. Family Data

Length of residency: ________________________

Place of origin: ____________________________
___________________________

Family size: ______________________________

Religion: Husband- _________________
Wife- _____________________

Family Member’s Chart

FAMILY AGE SEX CIVIL POSITION RELATIONSHIP EDUCATIONAL OCCUPATION

STATUS IN THE TO FAMILY ATTAINMENT
MEMBERS
FAMILY
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

III. Family Characteristics

Type of Family Structure

A. Extended ___________ D. Nuclear ___________

B. Matriarchal __________ E. Patriarchal _________
C. Dominant Family Member ___________________________

General Family Relationship/Dynamics

CRITERIA STATUS ADDITIONAL INFORMATION

Observable conflicts between family

members
Characteristics of communication
Interaction patterns among members

Family Dietary Habits

What did you eat yesterday? (24 hours dietary recall)

Breakfast: ______________________________________________________________
Lunch: ________________________________________________________________
Supper: _______________________________________________________________

Monthly Family Income Source

Husband: __________________________
Wife: __________________________
Others: __________________________

Family Health Status/Health History

Father: __________________________________________________________
Mother: __________________________________________________________
Children: __________________________________________________________

Monthly Family Income Source

Total (Check bracket)

below 500 _____ above P20,000- P30,000 _____
above P5,000-P10,000 _____ above P30,000-P40,000 _____
above P10,000-P15,000 _____ above P40,000-P50,000 _____
above P15,000-P20,000 _____ more than P50,000 _____

Felt Family Needs (Identify & rank according to priority)

FAMILY NEEDS RANK FAMILY NEEDS RANK

IV. Home and Environment

A. Is your lot owned? _____ Yes _____ No

B. Is your house owned? _____ Yes _____ No

C. Type of housing materials

_____ wood _____ makeshift
_____ concrete _____ others, specify
_____ mixed

D. Is the living space adequate? _____ Yes _____ No

E. What are the appliances owned by the family?

F. Type of garbage disposal

_____ collected _____ burning
_____ waste segregation _____ burying
_____ feeding to animals _____ throw in the river/sewer
_____ open dumping _____ others, specify _________________

G. Type of waste disposal

_____ flush _____ water-sealed
_____ wrap & throw _____ pit privy
_____ others, specify ____________________

H. Type of drainage system _____ Open _____ Closed

I. Source of water supply

_____ owned _____ shared
 _____ bought _____ others, specify _________________

J. Drinking water source

_____ refrigerated _____ covered
_____ uncovered

K. Containers used
_____ plastic pitchers _____ jars, clay pots
_____ bottles _____ others, specify _________________

L. Food storage/cooking facilities

_____ covered _____uncovered _____ stove
_____ refrigerator _____ cabinet _____ pots/pans, etc.

M. Common household pests found at home

N. Are there breeding sites of insects, rodents, etc. present

_____ Yes _____ No

O. Pets/animals kept in the yard/home

P. Are there accident hazards present? _____ Yes _____ No

V. Health and Health Practices

A. Common illnesses encountered for the last 6 months and the treatment
applied.

B. Whom do you consult for health-related problems?

_____ manghihilot _____ albularyo
_____ midwife _____ nurse
_____ doctor _____ health center
_____ barangay health worker _____ others, specify ___________

C. For problems other than health, whom do you consult?

_____ family members _____ relatives
_____ friends _____ barangay officials
_____ priest _____ others, specify ___________

D. Immunization status of family members

E. Have you had adequate

1. rest and sleep? ____ Yes _____ No
2. exercise? ____ Yes _____ No
3. relaxation activities? ____ Yes _____ No
4. stress management activities _____ Yes _____ No

VI. Environment

1. Kind of neighborhood
2. Social and health facilities available
3. Communication and transportation facilities

VI. Awareness of community organization

A. Are you aware of existing organizations in the community?
_____ Yes _____ No

B. Name all the organizations you know.

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, specify _____

F. Name 5 formal and non-formal leaders of the community whom you think
can lead the people.
1.
2.
3.
4.
5.

______________________________________________________________________
* Adapted from the Family Health Management Manual for Nursing Students Community Exposure Book 1 By Lydia C.
Viet, RN, MAN