Family No.
: ______
Name of Family Head: ________________________________________________
Address: ___________________________________________________________
List of Health Problems Nature of Problem
1.
2.
3.
4.
5.
Family No.: ______
Name of Family Head: ________________________________________________
Address: ___________________________________________________________
List of Health Problems Nature of Problem
1.
2.
3.
4.
5.
Family No.: ______
Name of Family Head: ________________________________________________
Address: ___________________________________________________________
List of Health Problems Nature of Problem
1.
2.
3.
4.
5.
Family No. _____________
Problem: _________________________
Criteria Standard Score Weight Actual Justification
Score
1. Nature of the Health deficit 3/ 1/
problem Health Threat 2 1 2/3
Foreseeable Crisis 1 1/3
2. Modifiability of Removable 2 2
the problem Partially modifiable 1/ 2 1/
Not modifiable 0 0
3. Preventive High 3/ 1/
potential Moderate 2 1 2/3
Low 1 1/3
4. Salience of the Needs immediate 2/ 1/
problem attention
Does not need 1 1 ½
immediate attention
Not a problem 0 0
TOTAL SCORE: ________________
Family No. _____________
Problem: _________________________
Criteria Standard Score Weight Actual Justification
Score
1. Nature of the Health deficit 3/ 1/
problem Health Threat 2 1 2/3
Foreseeable Crisis 1 1/3
2. Modifiability of Removable 2 2
the problem Partially modifiable 1/ 2 1/
Not modifiable 0 0
3. Preventive High 3/ 1/
potential Moderate 2 1 2/3
Low 1 1/3
4. Salience of the Needs immediate 2/ 1/
problem attention
Does not need 1 1 ½
immediate attention
Not a problem 0 0
TOTAL SCORE: ________________
Directions:
Rank the health problems of each family. Priority 1 has the highest score, priority 2 has the second highest,
priority 3, the next highest, and so on.
Ranking Health Problems Ranking Health Problems
Of Family ___________________________ Of Family ____________________________
PRIORITY PROBLEM SCORE PRIORITY PROBLEM SCORE
1 1
2 2
3 3
4 4
5 5
Ranking Health Problems Ranking Health Problems
Of Family ____________________________ Of Family ____________________________
PRIORITY PROBLEM SCORE PRIORITY PROBLEM SCORE
1 1
2 2
3 3
4 4
5 5
Ranking Health Problems Ranking Health Problems
Of Family _____________________________ Of Family ___________________________
PRIORITY PROBLEM SCORE PRIORITY PROBLEM SCORE
1 1
2 2
3 3
4 4
5 5