COLLEGE OF HEALTH SCIENCES
NOTRE DAME UNIVERSITY
COTABATO CITY
Surname of Family: _______
A. FAMILY STRUCTURE, CHARACTERISTICS AND DYNAMICS
Name Age Sex Civil Status Position in the Living with
Family Family or Not
A.1 Type of Family Structure (e.g. Patriarchal, Matriarchal, Nuclear, or Extended)
______________________________________________________________________________
______________________________________________________________________________
A.2 Dominant family member(s) in terms of decision-making especially in matters of health
care:
______________________________________________________________________________
______________________________________________________________________________
A.3 General Family Relationship/dynamics, characteristic communication, interaction,
patterns among members)
Do the family members talk with one another? How often?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
B. SOCIO-ECONOMIC AND CULTURAL CHARACTERISTICS
Name Occupation Place of Monthly Educational Ethnic Religion
Work Income Attainment Affiliation
(TRIBE)
Family
Member
A
Family
Member
B
Family
Member
C
Family
Member
D
Family
Member
E
Total Monthly income of the Family = ___
B.1 Breakdown of Expenses (Monthly)
Ex. Food/Groceries =
Electric Bills =
Water Bills =
Transportation =_
Allowance for Children’s =
Total Monthly Expenses of the Family = ______
B.2 Adequacy to meet basic necessities (food,clothing,shelter)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
B.3 Who makes decisions on money spending
______________________________________________________________________________
______________________________________________________________________________
B.4 Significant others (roles they play in family’s life)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
OTHERS: PLEASE SPECIFY
B.5 Relationship of the family to larger community (nature and extent of participation of
the family to community activities or if family member is associated with an organization).
______________________________________________________________________________
______________________________________________________________________________
C. Home and Environment
C.1 Adequacy of Living Space:
Living space: (Small, wide, approximate area
etc.)__________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
How many
rooms:________________________________________________________________________
______________________________________________________________________________
Is the house adequate for the size of the family members?
______________________________________________________________________________
____________________________________________________________________
C.2 Sleeping Arrangement:
Average range of time each family member sleeps: (Please specify what time for each member
of the
family)________________________________________________________________________
____________________________________________________________________________
Do family members sleep together or separately?
______________________________________________________________________________
C.3 Presence of breathing or resting sites of vector of diseases (e.g. mosquitoes, flies, and
etc.)
Is the house well ventilated and have adequate lighting?
______________________________________________________________________________
______________________________________________________________________
Are you living with pets? (If yes, how many? Please specify where they usually stay and any
observed good or bad habits or
illnesses)______________________________________________________________________
______________________________________________________________________________
Is there any presence of pests in the house? (If yes, please specify.)
______________________________________________________________________________
______________________________________________________________________________
Are there any accident prone areas present in the house? (If yes, please
specify.)_______________________________________________________________________
______________________________________________________________________________
C.5 Food Storage and Cooking Facilities:
Food Storage (Please Check.)
Refrigerated __
Not Refrigerated ____
Covered____
Uncovered___
Cooking Facility
Electric Stove ____
Gas Stove___
Firewood/Charcoal____
C.6 Water Supply (Source, ownership, portability) (Put a check.)
Level I- Point Source (Proacted well or a developed spring) ______
Level II- Communal Faucet System or Stand Posts (pipe distribution) _____
Level III- Waterworks System or Individual House Connections ____
Others: (Please specify)
_______________________________________________________________________
_______________________________________________________________________
C.7 Toilet Facility (Type, ownership, sanitary condition (Please Check.)
Level I- Non water carriage (pit latrines,pour flush toilet) _____
Level II-Water carriage (water sealed, flushed type with septic tank ___
Level III- Water carriage connected to septic tanks to a treatment plan _____
Others: (Please specify)
_______________________________________________________________________
_______________________________________________________________________
D. HEALTH STATUS OF EACH FAMILY MEMBER
Name Heigh Weight BM Vital Signs Past Illness(es) Present
t I Illness(es)
Family Member
A
Family Member B
Family Member C
Family Member
D
Family Member E
Treatment/Medication for past Illnesses:
______________________________________________________________________________
______________________________________________________________________________
FOR ILL MEMBERS OF THE FAMILY
NAM ILLNESSES PHYSICAL LABORATOR TREATMENTS/INTERVENTIO
E DIAGNOSED ASSESSMEN Y OR NS
OR T DIAGNOSTIC
UNDIAGNOSE RESULTS
D
D1. Dietary history(specify quality and quantity of food intake per day)
________________________________________________________________________
D2. Eating/feeding habits/practices (specify what foods family likes to eat usually)
________________________________________________________________________
D3. Presence of Risk factor assessment indicating presence of major and contributing modifiable
risk factors for specific lifestyle diseases (please check);
Hypertension: ___ Physical inactivity:___
Sedentary lifestyle: ___ Cigarette smoking: ____
Elevated blood cholesterol: ___ Obesity: _____
Diabetes mellitus: _____ Inadequate fiber intake: ____
Stress: _____ Alcohol drinking: ____
Substance abuse: ____
Others:________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
__________________________
E. VALUES, HABITS, PRACTICES ON HEALTH PROMOTION, MAINTENANCE
AND DISEASE PREVENTION
NOTE: FOR IMMUNIZATION COLUMN, PLEASE FILL OUT IF FAMILY
MEMBERS ARE VACCINATED WITH COVID-19 VACCINE (specify if
complete/incomplete/ incomplete with 1st/2nd dose) (also specify what type of vaccine: Pfizer,
Sinovac, Astrazeneca, moderna, etc)
NOTE: Please also indicate if children are fully immunized since birth.
USE OF
PROMOTIV
EXERCI USE OF STRESS
REST E-
IMMUNIZA SE/ PROTECTI MANAGEME
NAME AND PREVENTI
TION ACTIVIT VE NT
SLEEP VE
IES MEASURE ACTIVITIES
HEALTH
SERVICES
Family Use of face
Member masks, face
A shield,
frequent use
of alcohol,
and use
footwear
Use of face
masks, face
Family shield,
Member frequent use
B of alcohol,
and use
footwear
Use of face
masks, face
Family shield,
Member frequent use
C of alcohol,
and use
footwear
Use of face
masks, face
Family shield,
Member frequent use
D of alcohol,
and use
footwear
Family Use of face
Member masks, face
E shield,
frequent use
of alcohol,
and use
footwear
