Family Assessment Guide: Family Member's Chart

FAMILY ASSESSMENT GUIDE
Family Name: ___Anonymous___________ Address: ___Iloilo City_____
I. Family Data
Length of residency: 23 years______
Place of origin: Sta. Barbara, Iloilo__
Family size: ______7___________
Religion: Husband- Roman Catholic
Wife- Roman Catholic____
Family Member’s Chart
FAMILY MEMBERS AGE SEX CIVIL POSITION IN RELATIONSH EDUCATIONAL OCCUPATION

STATUS THE FAMILY IP TO ATTAINMENT
FAMILY
HEAD
1. Aa 48 M M Father Head Elementary Farmer
Graduate
2. Bb 40 F M Mother Wife High school Housewife
Graduate
3. Nene 23 F S Daughter Oldest High school Sales lady
Graduate
4. Nonoy 22 M S Son Second High school Construction
Graduate worker
5. Toto 20 M S Son Third College Student
6. Inday 17 F S Daughter Youngest Senior High Student
School
7. Bb 5 F S Grandchild Grandfather Student
II. Family Characteristics

Type of Family Structure: Extended _
Patriarchal
Tradition: Birthday
Christmas
New Year
Reunion
General Family Relationship/Dynamics
CRITERIA STATUS ADDITIONAL INFORMATION

Observable conflicts between family (-) None
members
Characteristics of communication (+) Respect each other
Interaction patterns among members (-) Not open to communicate
Family Dietary Habits
What did you eat yesterday? (24 hours dietary recall)
Breakfast: dried fish, rice, coffee, water
Lunch: Rice, tinola, ________
Supper: Rice, _______________
Monthly Family Income Source
Husband : _4000
Wife : none
Oldest child : _5400__
Second chils : 4000
Monthly Family Income Source
More than P 13400
Family Health Status/Health History
Father: Diabetes, and high blood __
Mother: High blood_______
Children: All children have Asthma, Oldest daughter- UTI
III. Home and Environment

A. Is your lot owned? No______
B. Is your house owned? __Yes______
C. Type of housing materials _Wood_
D. Is the living space adequate? No______
E. Sleeping arrangement Separated_
F. What are the appliances owned by the family?
,Television, Electric fan, Radio, _____________
G. Type of garbage disposal: _Burning_
H. Type of waste disposal: _Flush____
I. Type of drainage system: _Open____
J. Source of water supply: _”Nakiki-igib”____
K. Drinking water storage: _Jug.
L. Containers used: _Plastic bottles
M. Food storage/cooking facilities: Cabinet___
___”Kalan”__
N. Common household pests found at home: Cockroaches, mosquitoes, spiders, mouses,
and ants
O. Are there breeding sites of insects, rodents, etc. present? _Yes.
P. Pets/animals kept in the yard/home: _Dog and cat
Q. Are there any hazards present? _Yes________
IV. Health and health practices

A. Common illnesses encountered for the last 6 months and the treatment applied.
1. Father: _Diabetes with maintenance_
2. Mother: _High blood with maintenance
B. Whom do you consult for health-related problems?
Manghihilot
Doctor___
C. For problems other than health, whom do you consult?
Family members
D. Immunization status of the family members
_Complete immunization
E. Have you had adequate
1. Rest and sleep? _Yes__
2. Exercise _No__
3. Relaxation activities? _Yes__
4. Stress management activities? Yes_
V. Environment
1. Kind of Neighborhood Rural

2. Social and health facilities available Brgy. Health Center
3. Communication and Transportation Cellphone, laptop, Tricycle, Jeep, Motor
Facilities
VI. Awareness of community organization

A. Are you aware of existing organizations in the community? _Yes__
B. Name all the organization/s you know.
___Sangguniang Kabataan (SK)
___LGU____________________
C. Are you a member of any of these organizations? __No________
D. Are you aware of its activities and projects? __ Yes________
E. How are you involved in its activities? __Give donations
F. Name 5 formal and nonformal leaders of the community whom do you think can lead
the people.
1. Kapitan
2. Mayor
3. Kagawads
4. SK Chairman
5. Tanod
Family
Assessment
Submitted to:
Prof. Annalie Gilongos
Submitted by:
Jane Eloisa Gatsulao
Germaine Sarmiento Gelera
Carla Martina Mae Horario
Sophia Loraine Jesura
Marielle Jover
Christel Dawn Limsiaco

Jannah Mae Ma-ang
Krystian Macuja
BSN-2D

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FAMILY ASSESSMENT GUIDE

Family Name: ___Anonymous___________ Address: ___Iloilo City_____

Family Member’s Chart

FAMILY MEMBERS AGE SEX CIVIL POSITION IN RELATIONSH EDUCATIONAL OCCUPATION

II. Family Characteristics

General Family Relationship/Dynamics

CRITERIA STATUS ADDITIONAL INFORMATION

Family Dietary Habits

What did you eat yesterday? (24 hours dietary recall)

Breakfast: dried fish, rice, coffee, water

Lunch: Rice, tinola, ________

Supper: Rice, _______________

Monthly Family Income Source

Oldest child : _5400__

Second chils : 4000

Monthly Family Income Source

More than P 13400

Family Health Status/Health History

Father: Diabetes, and high blood __

Mother: High blood_______

Children: All children have Asthma, Oldest daughter- UTI

III. Home and Environment

IV. Health and health practices

1. Kind of Neighborhood Rural

VI. Awareness of community organization

Prof. Annalie Gilongos

Jane Eloisa Gatsulao

Germaine Sarmiento Gelera

Carla Martina Mae Horario

Sophia Loraine Jesura

Christel Dawn Limsiaco

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Family Name: _Anonymous_______ Address: _Iloilo City_____