University of Bohol

College of Nursing
City of Tagbilaran

Family Health Assessment Form

Family Surname: Dibdib_______________ Name of Family Head: B.A. Dibdib

House Number: 1958
Street__________________________Purok Number :2_______________
Purok Name: Barangay: Catagbacan___Municipality: Loon
Source of Information: Ma. D. S. Dibdib______ Relation: Mother_____
Data Gathered By: Crysthal S. Dibdib__ Date: September 17, 2021

[Link] Members:

No Family Sex Age Civil Relation Religion Educational Occupation

. Status to Head Attainment
Members
1 F 25 Single Daughte Roman College None
r Catholic level /student
Crysthal S. Dibdib

2 [Link] S. Dibdib F 24 Single Daughte Roman College Midwife

r Catholic
3. [Link] [Link] F 55 Marrie Wife Roman College Teacher
d Catholic

B. Family Characteristics:
Type of family structure
(/) Nuclear Family () Dyad Family () Compound Family

() Extended Family () Blended Family () Cohabiting Family () Single Parent Family

Name Age Relationship Location of Occupation/ Frequency Means of

to Head member Work of Contacts communication

Family Mobility
Length of time of current address: 7 years_____________________________________________
Address of Previous Residence: Montevista,Davao De Oro___________________________
Frequency of geographic move: 2________________________________________________

Family Dynamics:
Emotional Bonding of Family Members: During Birthdays and Special occasion
Distribution of Authority and Power ____________________________________________
How members communicate: Through personal and online communication

Dominant Members in terms of decision making __________________________________

(/) Husband () Wife () Adult Children () Others (specify) _______________

How are problems solved? Problems are solved through personal

conversation____________________________________________________
How is conflict handled? Conflict is handled through being calm and understanding each
other______________________________________________________
Division of labor: _____________________________________________________________

C. Socio Economic and Cultural Characteristics

Family Social Integration:
Languages or Dialect(s) Spoken :
(/) Visayan/ Cebuano (/) Tagalog (/) English () Others (specify) ____________________

Literacy (Ability to read and Write in language(s)

(/) Yes () No

Degree of social network with friends, neighbors and other relative _____________________

Network with religious organizations (name of organization of which the family members are involve)

_______________________________________________________________________________

Network with Social Organizations (name of the organizations of which family members are involve)

_______________________________________________________________________________

Educational experience____________________________________________________________

Work Experience _________________________________________________________________

Adequacy of Financial Resources:

Monthly Family Income source
Husband: 6,000___________________ Wife: 14,000 Others (specify)______________

Total Monthly Family Income: (please check)

() below P5000 () P21, 000-P30, 000

() P6, 000- P10, 000 () P30, 000-P40, 000
() P11, 000-P15,000 () P40,000- P50, 000
(/) P16, 000- P20, 000 () Above P50,000

Identify and rank according to priority family needs:

[Link]
[Link]
[Link]
[Link]
[Link]

Leisure Time (Name some leisure time activities you are interested at)- watching movies, listening to
music___________________________________.

D. Cultural Influences: Values/Attitudes/Beliefs about

Spirituality___________________________________________________________Filipino
Rituals (Holidays and Celebrations) Birthdays, Christmas, Christening, Fiesta
_______________________________________
Health ______________________________________________________________
Folk diseases N/A_________________________________________________________
Traditional Healer N/A_____________________________________________________

E. Family and Environment

1. Home
a. Ownership- (/) owned () rented () rent free

b. Construction Material
() light () mixed (/)Strong

c. Number of bedrooms:4___

d. Lighting facility
(/) Electricity () Kerosene () Others (specify)_________________

e. General sanitary condition :Good ______________________________________

2. Drinking and Water supply

a. source
Level 1 – (point source)

() shallow or deep well () improved Dug Well

()Developed spring (/) rain tank

Level 2 (communal faucet)

(/) waterworks system (/) Water refilling station

b. Distance from the house________near____________________________________

c. Storage:
() None (direct from the faucet)
(/)Large covered container with faucet
() Large uncovered container with faucet
 () Others (specify)___________________

3. Kitchen

a. Cooking facility used:

(/) electric stove (/)Gas stove
(/) firewood /Charcoal () Others (specify)________________

b. Food storage:
(/) Covered () Uncovered (/) Refrigerator
(/) container with cover
() container without cover

c. sanitary condition:Good_________________________

d. Drainage facility of kitchen:

(/)Open drainage
() blind drainage
() None

4. Waste Disposal

a. Garbage container

(/) covered () Open () none

b. Method of disposal

() Hog feeding () open burning () Open dumping

(/) garbage collection (/) burying in pit (/)Composting

() Others (specify) _________________________

c. Excreta disposal:

(/) Tank flush toilets (connected to septic tanks with sewerage system)

() Pour-Flush Latrine

() Ventilated-improved pit latrine

() Overhung latrine

() Antipolo toilet

() Pit latrine

() box and can privy

() Shared

() none

d. Distance from the house ___inside the house___________________

e. Sanitary condition (describe briefly the state of cleanliness) __Good______________

5. Domestic animals/common household pets

Kind Number Place kept

Dog 1 Dog cage

3 No cage

Cats

6. Pest and Vermin Control: Presence of breeding sites of insects, rodents, etc.

() Yes; specifically: ____________________________________________

(/) No

7. Presence of Accident Hazards: () Yes (/)No

If yes, Specify_______________________

() Broken parts of the house () Medicines (not kept)

() Sharp Objects (not kept) () Broken glasses

() stray animals

F. Family Neighborhood

a. Location: () urban (/) rural () subdivision () slum area

b. Type: (/) residential () Semi Commercial

c. Safety: (/) traffic patterns () Lighting () security ( private. /police)

(/) pedestrian lanes () walking pathways

d. Population Density (crowding)

() congested (/)non congested

e. Sources of pollution

(/) air () water () Soil () noise

f. Social and health facilities available

 (/)Barangay Health Station (/) Rural Health Units

(/) Private Clinics/Hospitals (/) Barangay Hall

() Chapel () Senior Citizen’s Hall

() basketball court () Purok Kiosk

g. Communication facilities of the family

(/)cellphone

() landline Telephone

(/) Computer/Laptop connected to internet

h. Transportation Facilities:

(/) Public Utility vehicle

(/) owned private cars

(/) own motorcycles

() rented vehicles

G. Family Health/Behavior

a. Activities of daily living (How the family spends a typical day)___________________________

Usual household chores and responsibilities.
_________________________________________________________________.

b. Health History:

1. Pregnancy:_________________________________________________________________

2. Illness: ____________________________________________________________________

3. Death within the past 5 years: (/) Yes () No

4. Health Attendance: (How Often)

(/) every month () once a year

() as the need arises () never () Others (specify)___________________

c. Self -Care Activities (name family’s related activities): Walking, Exercise, Regular vitamins
__________________________________

d. Risks Factor assessment for specific lifestyle diseases:

(/)Hypertension () Physical inactivity

() Sedentary lifestyle () Cigarette/tobacco smoking

(/)Elevated lipids/cholesterol (/) Alcohol drinking

 () Obesity (/) diabetes mellitus

() inadequate fiber intake (/) Stress

() poor diet () Substance abuse

() others (specify)_______________________________

e. Present Health Status:

A. Father/Head of the family: B.A.

Dibdib____________________________________________________

Vital Signs: T-_36.7 degrees centigrade. BP: 130/80 mmHg HR: 72 beats/min. RR:
20breaths/min _______________

Physical complaints: Knee Pain_______________________________

B. Mother/ Wife: [Link] Dibdib______

Vital Signs: T-36.4degree centigrade_ BP110/80mmHg_ HR 68bpm__ RR 19bpm_

Physical complaints:_Back pain________

C. Other members: Crysthal S.

Dibdib____________________________________________________________

Vital Signs: T- 36.7 degrees centigrade. BP: 110/70 mmHg HR: 71 beats/min. RR 18
breaths/min _______________

Physical complaints: None

_________________________________________________________

f. Common Illness encountered and management done

Age Illness Management

0-1

1-3

3-6

6-7

7-12

13-18

19-25 Cough Over the counter medicines

 Fever

Colds Clinic check-ups

Stress

Relaxation time

26-35

36-45

46-50

51-55

56-60 Taking of maintenance

prescribed by the doctor,
Elevated BP/ Hypertension
regular exercise, healthy
Diabetes mellitus diet. As well with regular
monitoring of Blood
pressure
60-up

g. Health Care Resources

a. Where do you consult for health related problems?

() “Manghihilot”/ Albularyo () BHW’s

(/) Physician/Doctor (/) RHU (MHO, PHN, PHM)

() Alternative treatment Clinics () Others (specify) _________________

b. For Problems other than health, whom do you consult?

(/) family member () relatives

() Friends () Priest

() Barangay Officials () Health workers

() Others (specify) ____________________________________

c. Immunization status of children:

Are the children immunized? (/) Yes () No

(/) Yes, if yes, check immunization received

(/) BCG (/) Hep B vaccine
(/) OPV (/) AMV
(/) Pentavalent vaccine (/) MMR
(DPT, Hep B. Hib)
d. Adequacy of:
1. Rest and sleep: (/) Yes () No

If No, Why? ___________________________________________

2. Exercise and Physical Activity: (/) Yes () No

If No, Why? ___________________________________________

3. Stress Management Activity/relaxation: (/) Yes () No

If No, why? ___________________________________________

If Yes, How often? () Daily (/) once a week

() Three times a week () once a month

() Never () Others (specify)_______