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FAMILY HEALTH ASSESSMENT

Head of the Family:_________________________________________________________________

Date:________________________Address (include important landmarks):_________________________________________________

_________________________________________________________________________________

I. Assessment of the Family

A. Members of the Household

NAMERelation to

Head

Se

x

Birth Date Ag

e

Marital

Status

Highest

Education

OccupationImmunization

Status

Physical

HealthMonth Year

Type of

WorkPlace

B. Type of Family Form:

C. Cultural and Religious Orientation:

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D. Social Class Status:1. Breadwinner:

2. Average Monthly Family Income:

E. Recreational or Leisure time activities: ____________________________________________

__________________________________________________________________________

II. PHYSICAL ENVIRONMENT

A. Home

1. Ownership:House: ( ) Owned ( ) Rental ( ) Rent-Free ( ) Others

Lot: ( ) Owned ( ) Rental ( ) Rent-Free ( ) Others

2. Construction materials used: ( ) Light ( ) Mixed ( ) Strong3. Number of rooms used for sleeping:

4. Specific room for ( ) kitchen and ( ) dining.

5. Furniture: ( ) None ( ) Limited ( ) Adequate

6. Home appliances present: ____________________________________________________

7. Lightning facilities: ( ) Electricity ( ) Kerosene

( ) Others, specify: ___________________________________

8. Safety hazards: ( ) loose rickety stairs

( ) loose doors, walls, postwindows: ( ) none, ( ) only 1, ( ) more than 1

sharps and matches within reach of children?

Yes/NoMedicines and poisonous substance kept side by side?

Yes/No

B. Kitchen1. Cooking facility: ( ) Electric stove ( ) Gas stove

( ) i d/ h l

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2. Collection containers:

CONTAINER WITH COVER WITHOUT COVER

a. bottles

b. cansc. pails

d. others (specify)

3. Storage

CONTAINER WITH COVER WITHOUT COVER

a. Jar (banga) w/ faucet

b. Jar (banga0 w/o faucet

c. Can

d. Pitcher

e. Pail

f. Others

D. Waste Disposal

1. Toilet

a. Type:TYPE OWNED SHARED

Open pit privy

Bored-hole latrine

Antipolo system

Pail system

Closed pit privy

Overhung latrine

Flush typeWater sealed

Other (speficy)

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E. Domestic Animals

KIND NUMBER WHERE KEPT

F. The Community in General1. Type of community:

RESIDENTIAL AREA INDUSTRIAL AREARural

Urban

Suburban

2. Accessible to: (encircle)

a. transportation YES/NO

b. church YES/NOc. school YES/NO

d. market YES/NO

e. shopping center YES/NOf. health agency YES/NO

3. Congested neighbourhood: YES/NO4. Recreational facilities present: ____________________________________________

5. Health care facilities present: _____________________________________________6. Distance of house to the nearest health care facility: _______________ (m)7. Family perception of this community _______________________________________

8. Family associations and transactions with the community:

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B, Family Communication1. Usual patterns: ( ) wheel ( ) isolate

( ) chain ( ) switchboard

2. Purposes:

3. Rules observed during interactions:

C. Family Stage of Development1. Present stage:

2. Developmental task demonstrated by the family at the present stage:

D. Role Structure

FAMILY MEMBER FORMAL ROLE INFORMAL ROLE

E. Power Structure

Decisions to be made Decision maker Decision-making process

1 Major family purchases

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F. Family Values1. Identified and practiced moral values .

2. How do these family values affect the health status of the family?

G. Family Coping Functions

1. Short-term stressors

2. Long-term stressors

3. Family strengths which counterbalance stressors

4. Functional coping strategies utilized by the family (past & present)

IV. HEALTH RELATED BEHAVIORSI. Family attitude towards:

1. health: __________________________________________________________

________________________________________________________________2. illness: __________________________________________________________

________________________________________________________________

II. Health care facilities:

1 l f h l h

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VI. Nutrition1. dietary practices and food allergies

2. food history record

SAMPLE MENU FOR ONE DAY

MEAL FOOD SERVED QUANTITYINDIVIDUAL

DIFFERENCES

3. market practices

VII. Sleep and Rest practices

FAMILY MEMBER TIME FOR SLEEPING TIME FOR WAKING SLEEPING AIDSUSED, IF ANY

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V. FURTHER ASSESSMENT DATA NEEDED:

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Criteria Computation Actual Score Justification

1. Nature of the problem

2. Modifiability of the

problem

3. Preventive potential

4. Salience of the

problem

Total Score

Criteria Computation Actual Score Justification

1. Nature of the problem

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Criteria Computation Actual Score Justification

1. Nature of the problem

2. Modifiability of the

problem

3. Preventive potential

4. Salience of the

problem

Total Score

Criteria Computation Actual Score Justification

1. Nature of the problem

2. Modifiability of the

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FAMILY NURSING CARE PLAN

HEALTH

PROBLEM

FAMILY

NURSINGPROBLEMS

GOAL OF CAREOBJECTIVES OF

CARE

INTERVENTION PLAN

Nursing

interventions

Method of Nurse-

Family Contact

Resources

required

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FAMILY NURSING CARE PLAN

HEALTH

PROBLEM

FAMILY

NURSINGPROBLEMS

GOAL OF CAREOBJECTIVES OF

CARE

INTERVENTION PLAN

Nursing

interventions

Method of Nurse-

Family Contact

Resources

required

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FAMILY NURSING CARE PLAN

HEALTH

PROBLEM

FAMILY

NURSINGPROBLEMS

GOAL OF CAREOBJECTIVES OF

CARE

INTERVENTION PLAN

Nursing

interventions

Method of Nurse-

Family Contact

Resources

required