FAMILY ASSESSMENT GUIDE
Family Name: LOZANO Address: Gun-ob Lapu-lapu City, Cebu
Demographic Data
Household no. A- 14 Barangay House no.
Family Data
Length of Residency 52 years
Place of Origin Cebu City
Family size 8
Religion
Husband Roman Catholic
Wife Roman Catholic
Family Members Chart
Relationship Educational
Family Members Ag sex Civil Status to Family Attainment Occupation
e Head
Edwin Lozano 52 M Married Head High School Rent-A-Van
Teofila Lozano 51 F Married Wife College Level Housewife
John Kenneth Lozano 31 M Single Child College G Seaman
Thom Edward Lozano 30 M Married Child College Level IT
Kerwin Lozano (deceased) 29 M Single Child High School n/a
John Carlo Lozano 20 M Single Child College Level n/a
Princess Marie Lozano 19 F Single Child College Level n/a
Nicole Karoline Lozano 11 F Single Child Elementary n/a
Family Characteristics
Types of Family Structure
Extended Nuclear ✔
Matriarchal Patriarchal
Dominant Family Member
General Family Relationship/Dynamics
Criteria Status Additional Information
Observable conflicts between family Often
members
Characteristics of communication Pluralistic
Interaction patterns among Random
members
Family Dietary Habits
What did you eat yesterday? (24 hours dietary recall)
Breakfast rice, egg and hotdog, one apple
Lunch rice and vegetable dish
Supper rice and chicken
Monthly Family Income Source
Husband occupation
Wife business
Others family members
Monthly Family Income Source
Total 30 K
Family Health Income Source
Father occupation, philhealth, SSS
Mother occupation, philhealth, SSS
Children occupation, philhealth,
Felt Family Needs (Identify and rank according to priority)
1 Employment 6 Utilities
2 Housing 7 Others
3 Education 8 Commodities
4 Health Insurance 9
5 Food 10
Home and Environment
Is your lot owned? Yes
Is your house owned? Yes
Type of housing materials
Wood makeshift
Concrete ✔ others, specify
Mixed
Is the living space adequate? Yes
What are the appliances owned by the family?
TV, refrigerator, stove, kitchen equipments, washing machine, home appliances etc.
Type of garbage disposal
Collected ✔ burning
Waste segregation burying
Feeding to animals throw in the river/ sewer
Open dumping others, specify
Type of waste disposal
Flush ✔ pit privy
Wrap and throw others, specify
Water-sealed
Type of drainage system is closed
Type of water supply
Owned ✔ shared
Bought others, specify
Drinking water storage
Refrigerated covered ✔
Uncovered
Containers used
Plastic pitchers ✔ jar, clay pots
Bottles others, specify glass
Food storage/ cooking facilities
Covered ✔ cabinet ✔
Refrigerated ✔ stove ✔
Uncovered pots/pans etc.
Common household pests found at home? Lizard and roach
Are there breeding sites of insects, rodents, etc. present? None
Pets/ animals kept in the yard/home? Dog
Are there accident hazards present? None
Health and Health Practices
Common illnesses encountered for the last 6 months and the treatment applied: Colds
Whom do you consult for health – related problems?
Manghihilot albularyo
Midwife nurse
Doctor ✔ health center ✔
Barangay Health Worker others/ specify
Immunization status of family members: Complete
Have you had adequate?
Rest and sleep Yes
Exercise Yes
Relaxation activities Yes
Stress management activities No
Environment
1 Kind of neighborhood Village
2 Social and health facilities available Health center, hospital
3 Communication and Transportation facilities Available
Awareness of Community Organization
Are you aware of the existing organization in your community? Yes
Name all the organizations you know?
The Cynefin Group
BADAC
Divine Mercy Chapel Org.
Are you a member of any of these organizations? Yes
Are you aware of its activities and projects? Yes
How are you involved in its activities?
Attend meetings ✔ give donations
Planning evaluation
Implementation ✔ others/ specify Volunteer
Name 5 formal and non-formal leaders of the community whom you think can lead the people.
1 Barangay Captain
2 Counselors
3 Cluster Chairmans
4 Non- profit org. Leaders
5 Purok/ Sitio Leaders
