I- Family structure, Characteristics, and Dynamics
A. Type of family
Nuclear- 3
Extended- 0
Others- 2
B. Family structure
Patriarchal- 1
Matriarchal- 4
C. Family size
Small- 2
Medium- 2
Large-1
D. Dominant family member in terms of decision- making, especially in matters of health care
Father- 4
Mother- 1
II- Socioeconomic and Cultural Characteristic
A. Employment status
Employed- 3
Unemployed- 2
Self- employed - 3
B. Monthly income per household
500- 999- 0
1000- 1999- 1
2000- 2999- 1
3000- 3999 - 1
4000- 4999- 1
5000- above- 1
C. Monthly expenses per household
500- 999- 0
1000- 1999- 1
2000- 2999- 1
3000- 3999 - 1
4000- 4999- 1
5000- above- 1
D. Adequacy to meet basic needs
More than adequate- 0
Adequate- 5
Not adequate- 0
E. Ethnicity
MERANAO 1
Bisaya 2
Maguindanaon 1
Tagalog 1
F. Religious affiliation
ISLAM- 2
Catholic- 3
G. Relationship of the family in community activities
1. Attendance in social activities
Yes – 5
No –
2. Participation in political activities
Yes – 3
No – 2
3. Participation in healthcare activities
Yes – 5
No –
H. Educational Attainment MOTHER FATHER
No formal education
Elementary level
Elementary graduate
High School level 1 0
High School graduate
College level
College graduate 4 5
III- Home and Environment
A. Residency
Less than 6 months-
More than 6 months- 5
B. Home ownership
Owned- 2
Rented- 3
Rented- free –
C. Land ownership
Owned- 2
Rented- 3
Rent- free –
D. Types of house
Concrete- 5
Wood-
Concrete/wood-
Makeshift-
E. Types of housing structures
Single- attached –
Single- detached- 5
Two- storey-
F. Electricity availability
With electricity- 5
Without electricity-
G. Means of cooking
Electricity stove- 5
Wood/charcoal-
Kerosene-
LPG-
Others-
H. Food storage
With refrigerator- 4
W/out refrigerator- 1
I. Water source
Deep well-
Communal-
Rain water-
Lake/river-
Other (water refilling station)- 5
J. Storage of drinking water
With cover- 5
W/out cover-
Others-
K. Garbage disposal
Compost pit-
Burning-
Collected- 5
Open dumping-
L. Type of toilet
Pit latrine-
Pail system-5
Septic tank/flush-
M. Drainage system
Open drainage-
Closed drainage- 5
IV- Health Care
A. Person to consult when family member are sick
Doctor- 3
Nurse/ midwife-
Faith healer-
Self- medication- 2
B. Type of birth attendants
Doctor- 3
Midwife- 1
Trained Hilot- 1
C. Place of delivery
Private hospital- 4
District hospital-
Health Center-
House- 1
D. Infant feeding practices
Breastfeeding- 3
Bottle feeding- 2
Mixed feeding-
E. Use of herbal medicines
Lagundi- 5
Bawang- 0
Tsaang- gubat – 0
Acapulo- 5
Ampalaya- 5
Sambung- 5
Bayabas- 5
Others-
F. Height and Weight BMI
G. Immunization of the children
Number of Children
Incomplete 1 (baby)
Complete 5
Fully Immunized 5
V- Responsible Parenthood
A. Family planning
Practicing FP- 5
Not practicing FP-
B. Method used in family planning
IUD-
Pills- 3
Condoms-
Ligation-
Rhythm- 2
Withdrawal-
Other-
VI- Health and Medical Records
A. Major illnesses
Hypertension- 2
Anemia- 1
DM- 1
Rheumatism- 1
Cardiac Disease-
PTB-
Pre- eclampsia-
Other
B. Common minor illness
Fever- 5
Toothache-
Colds- 5
Cough-
Headache-
Other-
C. Cause of Death
Hypertension-
Cancer-
Accident-
DM-
CVA-
Cardiac disease-
Pre- eclampsia-
PTB-
Liver disease-
FIRST LEVEL OF ASSESSMENT
I- Presence of Health Threats
A. Presence or family history of
Diabetes Mellitus 1
Cancer
Hypertension 3
Cardiovascular disease
Other: Arthritis 1
B. Presence of family members with communicable disease
Yes-
No- 5
C. Family size beyond what family resources can adequately provide
Yes- 5
No-
D. Presence of accident hazards
Broken chairs- 0
Pointed/Sharp objects- 0
Poison and medicines improperly kept- 0
Fire hazards- 0
Fall hazards- 0
Residence near river/lakes- 0
Others-
E. Faulty/unhealthy nutritional or eating habits or feeding techniques or practices
Inadequate food intake both in quality and quantity-
Excessive intake of certain nutrients-
Faulty eating habits- 5
Ineffective breast feeding/ faulty feeding techniques-
F. Stress provoking factors
Strained marital relationship-
Strained parent- sibling relationship-
Interpersonal conflicts between family members- 5
Care giver burden-
G. Poor home/environment condition or sanitation
Inadequate living space-
Lack of food storage facilities-
Polluted water supply-
Presence of breeding or resting sights of vectors of diseases-
Improper garbage disposal- 5
Poor lighting –
Poor ventilation-
Noise pollution-
Air pollution-
H. Unsanitary food handling and preparation
Yes-
No- 5
I. U healthy lifestyle and personal habits/practices
Alcohol drinking-
Cigarette/tobacco smoking- 1
Walking barefoot-
Eating raw meat or fish-
Poor personal hygiene-
Substance abuse-
Sexual promiscuity-
Engaging in dangerous sports-
Inadequate rest or sleep- 2
Lack of inadequate exercise/physical activity- 4
Lack of relaxation activities-
Non- use of self- protection measure-
Other-
J. Inherent personal characteristics
Yes-
No- 5
K. Inappropriate role assumption
Yes-
No- 5
L. Lack of immunization/inadequate immunization status of children
Yes-
No- 5
M. Presence of family disunity
Yes-
No- 5
II- PRESENCE OF HEALTH DEFICITS
A. Presence of illness
Diagnosed- 3
Not diagnosed- 2
B. Failure to thrive/develop according to normal process
Yes-
No- 5
C. Presence of disability
Yes-
No- 5
III- PRESENCE OF STRESS POINTS/FORESEEABLE CRISIS SITUATIONS
Marriage- 2
Pregnancy, labor, puerperium-
Parenthood- 5
Additional member- 1
Entrance at school-
Adolescent-
Divorce/separation-
Menopause-
Loss of job-
Hospitalization of a family- 5
Death of family member-
Resettlement in new community-
