Download - Family Health Assessment
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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