2021 Family Assessment Tool

COLLEGE OF NURSING
CARLATAN, SAN FERNANDO CITY, LA UNION
FAMILY ASSESSMENT GUIDE

COMMUNITY NEEDS ASSESSMENT /MINIMUM BASIC NEEDS (MBN) FORM
Date:
Family Name:
I. Demographic Data
Household Number: Barangay House Number:
II. FAMILY DATA
Length of Residency: Place of origin:
Family Size: Religion: Husband: Wife:
FAMILY MEMBER’S CHART
FAMILY MEMBERS AGE SEX CIVIL POSITION RELATIONSHI OCCUPATION

EDUCATIONAL
STATUS IN THE P TO THE
FAMILY FAMILY
ATTAINMENT
HEAD
III. FAMILY CHARACTERISTICS
Type of Family Structure

A. Extended: B. Matriarchal: _____ C. Dominant Family Member: ___
D. Nuclear: _____ E. Patriarchal: _____
General Family Relationship/Dynamics

CRITERIA STATUS ADDITIONAL
INFORMATION
Observable conflicts between family
members
Characteristics of communication
Interaction patterns among members
Family Dietary Habits

What did you eat yesterday? (24 hours dietary recall)
Breakfast: Lunch:
Dinner/Supper:
Monthly Family Income Source

Husband: ___________________________ Wife: ______________________________
Others: ________________________________________________________________
below Ph 5,000_____ above PhP 20,000- 30,000 __________

above Ph 5,000-10,000____ above PhP 30,000- 40,000___________
above Ph 10,000- 15,000___ above Ph 40,000- 50,000 ____________
above Ph 15,000-20,000____ above Ph 50,000
FAMILY HEALTH STATUS/HEALTH HISTORY

Father:
Mother:
Children/s:
FELT FAMILY NEEDS (Identify and rank according to priority)
1. Food 5. Shelter
2. Water 6. Medicines
3. Money 7. Access to healthcare services
4. Education 8. Clothing
IV. HOME AND ENVIRONMENT
A. Is your lot owned? YES NO_________________
B. Is your house owned? YES NO_________________
C. Type of Housing materials? wood ____________ concrete:
Mixed: ______ makeshift: _____ others, specify__________________________
D. Is the living space adequate? YES NO____________________
E. What are the appliances owned by the family?
F. Type of Garbage Disposal
__________Collected __________burning
__________Waste segregation burying
__________ feeding animals __________throw in the river
__________open dumping __________ others, specify _____
G. Type of waste Disposal
__________Flush __________ water-sealed (private)
__________wrap and throw __________ pit-privy
dig and bury _________water-sealed (communal)
Others,specify_____________________________________________________
H. Types of Drainage System __________Open Closed
I. Source of water owned _____________bought __________shared
Others, specify ___________________________________________
J. Drinking water storage
refrigerated ________Covered Uncovered: ____________________
K. Container used
Plastic pitchers _____________jars /clay pots
bottles _____________others,specify
L. Food Storage/ Cooking facilities
Covered ______________Uncovered Stove
Refrigerator Cabinet Pots/pans
M. Common Household pests found at home
1.
2.
3.
N. Are there breeding sites of insects, rodents present? YES______________NO
O. Pet/ Animals kept in the home/Yard
P. Are there hazards present? YES _______________ NO ________
V. HEALTH and HEALTH PRACTICES
A. Common illnesses encountered for the last 6 months and treatment applied
___________ diarrhea ______ colds ____________cough
____________influenza______stomach pains______headache
____________toothache_____Hypertension________Diabetes
____________gastritis ________ __________________others, specify
B. Whom do you consult for health-related problems?
___________” Manghihilot “ __________midwife
__________Doctor __________BHW
___________quack doctor/ albularyo __________Clinic
self-medication others, specify___________________________
C. For problems other than health, whom do you consult?
family members relatives
friends __________barangay officials
___________priest Others, specify ______________________________
D. Immunization status of family members-
Head of the family
Wife
Children
E. Have you had adequate?
_____1. Rest YES NO______
_____2. Exercises YES _____ NO
_____3. Relaxation Activities YES NO______
_____4. Stress management YES NO______
VI. KIND OF NEIGHBOORHOOD

1. Kind of Neighborhood
2. Social and Health facilities available
3. Communication and transportation
V. AWARENESS OF COMMUNITY ORGANIZATION

A. Are you aware of the existing organizations in the community? YES NO_________
B. Name all the organizations you know?
C. Are you member of these organizations? YES NO_____________
D. Are you aware of its activities and projects? YES NO_____________
E. How are you involved in its activities?
______1. Attend meeting ______4. Give donations
______2. Planning _______5. Evaluation
______3. Implementation others, specify_____________________
F. Name five (5) formal and non-formal leaders of the community whom you think can lead the
people?
POSITION
1.
2.
3.
4.
5.
Interviewer

2021 Family Assessment Tool

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COLLEGE OF NURSING

CARLATAN, SAN FERNANDO CITY, LA UNION

FAMILY ASSESSMENT GUIDE

FAMILY MEMBER’S CHART

FAMILY MEMBERS AGE SEX CIVIL POSITION RELATIONSHI OCCUPATION

III. FAMILY CHARACTERISTICS

Type of Family Structure

General Family Relationship/Dynamics

Family Dietary Habits

Monthly Family Income Source

below Ph 5,000_ above PhP 20,000- 30,000 ______

FAMILY HEALTH STATUS/HEALTH HISTORY

VI. KIND OF NEIGHBOORHOOD

V. AWARENESS OF COMMUNITY ORGANIZATION

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