ARELLANO UNIVERSITY – PASIG
Andres Bonifacio Campus
Pag-asa St.,Caniogan, Pasig City
COMMUNITY HEALTH NURSING
INITIAL DATA FOR FAMILY ASSESSMENT
PART I. Identification information
Date:_____________
Name of Person Interviewed:___________________________________________________
Address: House No.:_________, Street:________________________________________
City:________________________________________________________________________
A. Family Members Profile:
Family Structure and Characteristics
Name Position in the Sex Age Civil Highest
family Status Education
Completed
Other person living in the house
Types of Family Structure:
Nuclear_____ Extended_____ Patriarchial____ Matriarchal____
Who makes decisions regarding health care?_ _________
General family relationship:
_____ With conflicts between members
_____ without conflicts between family members
Socio – Economic and Cultural Factors:
Name Occupation Employment Income Place of work
Status
Other person living in the house
Does the working family members meets the basic necessities? ____YES ____NO
Who makes decision regarding money matters? ________________________
What role does the family play in the community? ______________
What’s the participation of the family in the community activities_________________
Total Monthly Income of Household:
[ ] below 1,000/month [ ] Php 1,000-3,000/month
[ ] Php 3,000-5,000/month [ ] Php 5,000-10,000/month [ ] above 10,000/month
PART II. Environmental Factors of your House
Home ownership:
[ ] Owned [ ] shared [ ] rental
Housing: Adequacy of living space:
Number of rooms: [ ] 1 room [ ] 2 rooms [ ] 3 rooms
Number of person/s per room: ___________(specify)
Housing Structure:
[ ] concrete (strong material) [ ] mixed (combination of wood and concrete)
[ ] light (wood, bamboo, nipa)
Lightning Facilities:
[ ] electric bulb [ ] used of kerosene lamp [ ] others _______
Sources of Electricity:
[ ] owned [] shared
Communication and Transportation facilities available: ____cellphone____
Environmental proximal to the house:
[ ] near factories [ ] near dumpsite
[ ] near creek/river [ ] near the fields
Toilet Facility:
[ ] water-sealed [ ] flush-type [ ] open pit-hole privy
[ ] over-hung lantrine [ ] antipolo-type [ ] closed pi-hole privy
Garbage Disposal:
[ ] thrown/open dumping [ ] collected (frequency) ____________X a week
[ ] open burning [ ] composting
[ ] burial pit
Kind of neighborhood:
[ ] slum [ ] congested
Drainage:
[ ] close drainage [ ] open drainage [ ] none
Infestation of Insect and Rodents:
Are insect and rodents present in your house:
[ ] yes [ ] no
Presence of Domestic animals:
Kind of Animal Number Where kept:
[ ] dogs _______ [ ] loose [ ] tied/kept in backyard
[ ] cats _______ [ ] loose [ ] tied/kept in backyard
[ ] cow _______ [ ] loose [ ] tied/kept in backyard
[ ] carabao _______ [ ] loose [ ] tied/kept in backyard
[ ] pigs _______ [ ] loose [ ] tied/kept in backyard
[ ] chicken _______ [ ] loose [ ] tied/kept in backyard
[ ] others _______ [ ] loose [ ] tied/kept in backyard
If with dogs, are they vaccinated or not?
[ ] vaccinated [ ] unvaccinated
PART III. Health Assessment of Each Member
Medical History
Family History of Disease
[ ] Diabetes [ ] Tuberculosis [ ] Heart Disease [/] Hypertension
[ ] Hepatitis B/C [ ] Mental Illness [ ] Asthma [ ] Food Allergy
[ ] Hemophilia [ ] Cancer [ ] Skin Allergy/Skin Disease [ ] Abnormalities
Present Illness (starting January 2024)
[ ] Diabetes [ ] Tuberculosis [ ] Heart Disease [ ] Hypertension
[ ] Hepatitis A [ ] Pneumonia [ ] Fracture [ ] Hepatitis B
[ ] Migraine [ ] Asthma [ ] Food Allergy [ ] Diarrhea (more than 3 days)
[ ] Cancer [ ] Skin Allergy [ ] Respiratory Illness (cough more than 1 week)
[ ] Typhoid Fever [ ] Bleeding [ ] Dengue Fever [ ] Anemia
[ ] Malnutrition [ ] others:________________
Chronic Illness
[ ] Diabetes [ ] Tuberculosis [ ] Heart Disease
[ ] Hypertension [ ] Hepatitis B/C [ ] Cancer
Sources of Health Care of Family: (frequently used service)
[ ] Health Center [ ] Private Clinics [ ] Traditional Doctor
[ ] Private Hospital [ ] Government Hospital [ ] others_________(specify)
Recreational Facilities:
Parks ( ) Playground ( ) Amusements center ( )
Source of Health Insurance:
[ ] SSS [ ] Phulhealth [ ] Private Health Card [ ] others_________(specify)
Vaccination against: [ ] Influenza [ ] Hepatitis B [ ] Cervical Cancer/HPV
Immunization Status of Children: (Name, Age, Complete/Incomplete)
Name Age Complete Incomplete
Rest and Sleep: _________
Exercise: __________
Relaxation activities: ___________
Stress Management activities:
Meditation ( ) Deep breathing ( ) Physical Exercise ( )
Social media ( ) Others: _________________
Vices
[ ] Smoking_______(note number of sticks per day)
[ ] Alcoholism____ocasionally____(note number of bottles per day)
[ ] Prohibited drugs________(specify)
Beliefs and Practices in case of emergency medical problem:
[ ] Consult medical practitioner
[ ] Use herbal medicine
[ ] Consult hilot, albularyo and espiritista
[ ] Self-medication/self-treatment
[ ] Traditional theraphy such as reflexology, acupressure, acupuncture
[ ] others
For Females: Do you conduct or submit yourself for the following procedure:
[ ] Monthly self-breast examination
[ ] yearly Pap Smear
[ ] annual physical examination
[ ] others
For Males: Do you conduct or submit yourself for the following procedure:
[ ] Testicular Examination
[ ] annual physical examination
[ ] others
Nutritional Assessment
Typical Diet per day:
[ ] vegetarian [ ] carnivorous [ ] mixed
Food Preference when cooked:
[ ] inihaw/grilled [ ] nilaga/boiled or blanch [ ] ginisa/sautéed
Quantity of meal per day:
[ ] 6 x a day [ ] 5x a day [ ] 4x a day [ ] 3x a day [ ] 2x a day [ ] 1x a day
Hospitalized member of the family (since January 2023 up to the present):
Name Age Gender Date Admitted Diagnosis Medical/Surgical
in Hospital Management
Deaths from January 2023 up to present
Name Age Gender Date Died Cause of Death Relationship
Additional Questions
1. Do they still practice the COVID-19 Protocol of Physical distancing, wearing of masks and face shields, not
being allowed to go out because they belong to the most vulnerable (the Senior Citizens) groups to contact the
disease).
// YES NO
/
2. At present, do they still feel fear of contacting COVID-19? YES NO
3. What are their plans when someone in the family gets COVID-19?
/ Consult at the health center Don’t seek any medical personnel, just stay at home