WESTERN MINDANAO STATE UNIVERSITY

College of Nursing
Health Care 1B
FAMILY ASSESSMENT GUIDE
Family Name ______________________________ Address: ___________________________
Purok/Zone/Drive____________________

I. Demographic Data
Barangay House No: _______
II. Family Data
Length of Residency: _______ Family size: ______________
Religion: _________________ Dialect: _________________
Ethnicity: _________________

Family Members and Significant Other’s Chart

FAMILY MEMBERS AGE SEX CIVIL POSITION IN RELATIONSHIP EDUCATIONAL OCCUPATION MONTHLY
STATUS THE FAMILY TO FAMILY ATTAINMENT INCOME
HEAD

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
What decisions do family members make? What roles and responsibilities do they have?

Family Members Decisions They Make Roles & Responsibilities

What is good about your family? __________________________________________________________

_____________________________________________________________________________________

What difficulties do you encounter about your family? ________________________________________

_____________________________________________________________________________________

What other available resources do you have that can help meet the basic needs of the family?
III. Family Health and Health Practices

A. Family Health Status, Health History and General Appearance.

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

B. Immunization status of family members (0-6 year’s old and pregnant mother).

C. Family Dietary Habits

What do you usually eat? (Dietary recall)
Breakfast: _____________________________________________________________________
Lunch: ________________________________________________________________________
Supper: _______________________________________________________________________
Merienda : _____________________________________________________________________

D. Health Practices/Habits.
What practices do you have to keep healthy? _________________________________________

E. Describe common illness encountered for the last 6 months, the treatment/effectiveness of
treatment.

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

Types of Problem
1.Albularyo/Maninilik
2.Manghihilot/Panday
3.Barangay Health Worker
4.Midwife
5.Nurse
6.Doctor
7.Others, specify
G. For problems other than health, whom do you consult?
Types of Problem
1. Family Members
2. Relatives
3.Friends
4.Barangay Officials
5.Priest
6.Others, specify

H. Felt Family needs (Identify and rank according to priority)

1. 6.
2. 7.
3. 8.
4. 9.
5. 10.
Other remarks:
 IV. Home and Environmental (observe as needed)
A. General description

B. Is your lot owned? ____Yes ____No

C. Is your house owned? ____Yes ____No

D. Type of housing materials

____wood _____mixed _____concrete ____makeshift ____other, specify

Remarks:
E. Describe the living space.

F. What are the appliances owned by the family?

G. Types of garbage disposal

_____collected _____burning
_____waste segregation _____burying
_____feeding to animal’s _____throw in the river/sewer
_____open dumping _____others, specify

H. Type of waste disposal

_____flush _____water-sealed
_____wrap and throw _____put privy
_____others, specify ______________

I. Type of drainage system _____Open _____Closed (Observe)

J. Source of water supply
_____owned _____shared
_____bought _____others, specify ______________

K. Possible sources of contamination(Observe) ________________________________

L. Drinking water storage _____ refrigerated _____covered _____uncovered
Remarks:

M. Containers used _____plastic pitchers _____jars, clay pots _____bottles _____others, specify
Remarks:

N. Food storage cooking facilities

_____covered _____uncovered _____stove
_____refrigerator _____cabinet _____pots/pans, etc

O. Common household pets found at home.

P. Are there breeding sites of insects, rodents, etc. present? _____(Yes) _____(None)
 Q. Pets/Animals kept in the yard/home

R. Are there accident hazards present? _____(Yes) _____(No)(Observe)

Other remarks:

V. Involvement in community organizations/projects

A. What organizations exist in the community? What services do they offer?

Organization Services Offered

B. Which services of organization do you avail of? ____________________________________

C. Are you involved in any of these organizations? In what way?

Name Possible Projects

Other remarks:

VI. Capacity and Skills Inventory

A. What skills or talents do any family members have?

Family Members Talents/Skills Training/Experience

B. Which of all your skills are good enough that other people would hire to do them?
1. _______________________________________________________________
2. _______________________________________________________________
3. _______________________________________________________________

C. Are there any skills that you have that you could teach to others?
1. _______________________________________________________________
2. _______________________________________________________________
3. _______________________________________________________________

D. What skills would you most like to learn?

1. _______________________________________________________________
2. _______________________________________________________________
3. _______________________________________________________________

Other remarks:
 COMMUNITY RELATED LEARNING EXPERIENCE REQUIREMENTS

FAMILY HEALTH NURSING PROCESS

A. ASSESMENT
1. Initial Data Base
e.g. Tool
2. First Level Assessment
3. Second Level Assessment
4. Ranking of Problem (Prioritized Problem)

B. FAMILY NURSING CARE PLAN

Health Family Goal or Objective of Nursing Rationale Implementation Evaluation
Problem Nursing Care Care interventions
Problem

First Level Second

Level

C. HEALTH TEACHING PLAN

Subject Matter:

Time Allotment:

General Objective:

Specific Content Time Strategies Resources Evaluation

Objectives Allotment

Prepared by: Level II Faculty