I.

Assessment of the Family, Home and Environmental Conditions:

A1. Members of the Household
FAMILY RELATION SEX BIRTHDATE MARITAL HIGHEST OCCUPATION REMARKS /
MEMBER TO STATUS EDUC. DATE
HEAD COMPLETE ENTERED
D
No. Name Month Year Type place
of
work

FAMILY RELATION SEX BIRTHDATE MARITAL HIGHEST OCCUPATION REMARKS /

MEMBER TO STATUS EDUC. DATE
HEAD COMPLETE ENTERED
D
No. Name Month Year Type place
of
work

A2. Family Members not residing in the household but affect family resource generation and use
FAMILY RELATION S BIRTHDATE MARITAL HIGHEST OCCUPATION REMARKS /
MEMBER TO HEAD E STATUS EDUC. DATE
X
COMPLET ENTERED
ED

No. Name Month Year Type place

of
work
A. Home and Environment
Date Assessed: ________________________________________________

1. Home

a. Ownership: ( ) owned ( ) rented ( ) rent-free

b. Construction materials used: ( ) Light ( ) Mixed ( ) Strong

c. Number or rooms used for sleeping: ___________________

d. Ventilation: ( ) poor ( ) good

e. Lighting Facilities: ( ) Electricity ( ) Kerosene ( ) Others: Specify

f. Location (e.g., urban or rural, subdivision, slum area)

___________________________________________________

g. Type (e.g., residential, semi commercial)

_____________________________________________________________

h. General sanitary condition: ___________________________________________________

2. Drinking Water Supply

Source: ( ) artesian well ( ) NAWASA

( ) deep well

Portability: _________________________________________________________

Distance from house: __________________________________________

Storage: ( ) none (direct from faucet or pipe)

( ) refrigerated

( ) large
uncovered
container without
faucet
( ) others, specify
Containers used:
( ) plastic ( ) clay jars

( ) bottles others: __________________________________________

3. Kitchen

Cooking facility: ( ) electric stove ( ) gas stove ( ) firewood/charcoal

Sanitary condition: ____________________________________________________

Drainage facility: ( ) open drainage ( ) blind drainage ( ) none

4. Waste Disposal

a. Refuse and garbage

Container: ( )
covered ( )
open ( ) none
Method of
disposal:
( ) hog feeding ( ) open burning

( ) open dumping ( ) garbage collection

( ) burial in pit ( ) others, specify: ____________________________

( ) composting

b. Toilet

Type:

Sanitary
( ) none ( )
pail system ( )
overhung
latrine ( )
Antipolo type

( ) open pit privy ( ) water-sealed latrine

( ) closed pit privy ( ) flush type

( ) bored-hole latrine

( ) others,
specify:_____________________________________________________

Unsanitary: ( ) Ballot System Others: ___________________________

Distance From House :____________________________________________

Sanitary condition:_______________________________________________
 5. Food storage:
( ) covered
( ) refrigerated
( ) uncovered
6. Background gardening:
( ) vegetables ( ) herbal
( ) fruit-bearing others ______________________
Domestic animals:
KIND NUMBER AREA KEPT

8.The Community in General

a. General sanitary condition: ________________________________________
b. Housing congestion: ( ) Yes ( ) No c. Presence of Breeding
c. Sites of Vectors of Diseases:
( ) Yes; Specify _________________________
( ) None
d. Recreational facilities: ________________________________________
e. Availability of health care services (describe briefly):________________________
_________________________________________________________________
__________________________
f. Distance of house from nearest health care facility: _______________________
_________________________________________________________________
___________________________
II.Socio-Economic Data
A.Source of Income Occupation:
Husband Wife
( ) Employed ( ) Unemployed
( ) Self-employed
Monthly Income:
( ) Below ₱ 2,000 ( ) ₱2,000-₱5,000
( ) ₱5,001-₱8,000 ( )more than ₱8,000
B.Family Expenditures
1. Food
( ) Below ₱50 ( ) ₱50-75
( ) More than ₱70
 2.Clothing: number of times of times of buying
( ) Once a year ( ) twice ( ) Thrice
3.Housing
( ) Water ( ) electricity ( ) Telephone ( ) Schooling
4.Schooling
( ) Public ( ) private
5.Others _________________________________________
III.Knowledge, Attitude and Practice
A. Do you utilize the health center? ( ) Yes ( ) No
If no, why? ______________________________________________________________
B. Reason:
( ) illness ( ) prenatal
( ) family planning ( ) postnatal
( ) dental ( ) nutrition
C.First person consulted in times of illness:
( ) M.D. ( ) nurse
( ) Midwife ( ) “hilot”
( ) “herbularyo” ( ) BHW
Others ______________________________
D.Usual illness in the family
___________________________________________________________________
_______________________________________________________________________
_____ What do you do for this condition?
( ) Self-medication ( ) consultation
( ) hospital ( ) private clinics
( ) nursing others _______________________
E. Other diseases
( ) TB ( ) Leprosy
( ) Skin disease ( ) Hepatitis
Others ____________________
F.Do you submit your children (0-12 months) for immunization?
Name of child Birthday Immunization

BCG DPT OPV AM

 G. Do you practice family planning? ( ) Yes ( ) No Method:
If no, why? __________________________________________________________________
H. Method of infant feeding
( ) breast
( ) bottle ( )
mixed
I. Subjects you want to learn in health education:
( ) drug douse ( ) nutrition
( ) family planning ( ) herbal plants
( ) first aid measure
others __________________
IV. Cultural influences: Values, attitude and
beliefs about:
A. Spirituality
____________________________________________________________________________
___________________________________
B. Rituals (holidays and celebration)
____________________________________________________________________________
___________________________________ __________
C. Dietary habits:
____________________________________________________________________________
____________________________________________________________________________
_____________________________________________

D. Health:______________________________________________________________________
____________________________________________________________________________
______________________________________________
E. Folk Diseases: ____________________________________________________

F. Traditional healers: ______________________________________________

V. Family Dynamics
A. Emotional bonding of Family members:
____________________________________________________________________________________
__________________________________________________
B. Distribution of authority and power:
____________________________________________________________________________________
_______________________________________________
C. C. Degree of individual autonomy:_________________________________________________
D. D. How members communicate:__________________________________________________
E. E. How decisions are made: ____________________________________________________
 F. F. How problems are solved: _______________________________________________
G. G. How conflict is handled: ___________________________________________________
VI. Socioeconomic and cultural characteristics
A. Language(s) or dialect(s) spoken: __________________________________
B. Literacy (ability to read/write in language(s)______________________________
C. Degree of social network w/ friends, neighbors and other relatives:
_______________________________________________________________________________
________________________________
D. Network with religious organizations:
_______________________________________________________________________________
________________________________
E. Network with social organizations:
_______________________________________________________________________________
________________________________
F. Adequacy of financial resources:
_______________________________________________________________________________
________________________________
G. Leisure time interest:
_______________________________________________________________________________
________________________________
VII. Community Resources
A. Health and other facilities
( ) health center ( ) barangay hall
( ) school ( ) church
( ) park ( ) market
B. Indigenous health workers
( ) trained “hilot” ( ) BHW
( ) herbularyo ( ) untrained “hilot”
Others ____________________ C. Sources of health funds:
( ) government ( ) private
NGOs/ Pos Others ______________________
VIII. Nutrition
A. Food preference
( ) Fish ( ) fruits / vegetables
( ) Meat ( ) mixed
C. Common fare
( ) rice and egg ( ) rice and sardines others
( ) Rice and noodles
 D. Presence of nutritional disorder
1.Goiter
( ) enlargement of neck ( ) dysphagia
( ) hoarseness others __________________________
2.Anemia
( ) pallor ( ) easy fatigability
( ) body weakness
3. Vitamin A deficiency
( ) night blindness
Others _____________________________
A. Health Condition and Problem Sheet
HEALTH NURSING SUPPORTING / DATE
CONDITIONS PROBLEMS CUES
AND PROBLEMS
IDENTIFIED RESOLVED

B. Nursing Care Plan

HEALTH OBJECTIVES OF PLANS OF PRINTED NAME AND
CONDITION/S INTERVENTION SIGNATURE
NURSING CARE
OR PROBLEM/S
AND
FAMILY
NURSING
PROBLEMS

OUTCOME METHODS/
CRITERIA/
TOOLS
INDICATORS,
STANDARDS
 C. Service and Progress Notes
DATE HEALTH CONDITIONS / NURSING OBSERVATIONS, ACTION/S PRINTED NAME
NURSING TAKEN, AND SIGNATURE

PROBLEMS RESPONSES and EVALUATION OF

PROGRESS/OUTCOMES

Interviewed by: _____________________________

Date: _________________Time: _______________