WESLEYAN UNIVERSITY-PHILIPPINES

STUDENT’S NAME AND BLOCK:

COMMUNITY HEALTH NURSING (COPAR)

FAMILY ASSESSMENT GUIDE

Family name : ______________________________

Address :_______________________________

I. DEMOGRAPHIC DATA
Household number:

1. FAMILY DATA
a. Length of residency:
b. Husband’s place of origin:
c. Wife’s place of origin:
2. FAMILY MEMBER’S CHART
Family members Civil Position in Relationship to Educational
Age Sex Occupation
status the family family head Attainment
1
2
3
4
5
6
7
8
9
10

II. FAMILY CHARACTERISTICS

TYPE OF FAMILY STRUCTURE (tick the appropriate box)

1 Nuclear
2 Extended
3 Single parent family

4 Childless family

5 Step family

6 Grandparent family

7 OTHERS

A Matriarchal

B Patriarchal
Dominant family member

III. GENERAL FAMILY RELATIONSHIP/DYNAMICS

CRITERIA STATUS ADDITIONAL INFORMATION

negative positive

1. Observable conflicts between family members

2. Characteristics of communication
3. Interaction patterns among members

IV. FAMILY DIETARY HABITS

What did you eat yesterday? (24-hour dietary recall)
 Breakfast lunch supper

V. MONTHLY FAMILY INCOME SOURCE

1. HUSBAND:___________
2. WIFE:________________
3. OTHERS:
Monthly Family Income Amount (Check bracket)
Below P5,000.00 Above 20,000 – 30,000.00
Above 5,000.00 – 10,000 Above 30,000 – 40,000.00
Above 10,000 – 15,000 Above 40, 000 – 50,000.00
Above 15,000 – 20,000 More than 50,000.00

VI. FAMILY HEALTH STATUS/HEALTH HISTORY

1. Father

2. Mother

3. Children

4. Other members of the

family (indicate who)
5. Cause of death in the
family in the last 5 years

VII. FELT FAMILY NEEDS

IDENTIFY AND RANK ACCORDING TO PRIORITY
1
2
3
4
5
6

VIII. HOME AND ENVIRONMENT

(Tick the appropriate box)
YES NO
1. Is your lot owned?
2. Is your house owned?
3. Is the living space adequate?
4. Type of housing material 5. What are the appliances owned 6. Type of garbage disposal
by the family?
a. Wood a. a. Collected
b. Concrete b. b. Waste segregation
c. mixed c. c. Feeding to animals
d. makeshift d. d. Open dumping
e. others (specify) e. e. burning
f. f. burying
g. g. throw in the river/sewer
h. h. others (specify)
7. type of waste disposal 8. Type of drainage system 9. Source of water supply

a. flush a. Open a. Owned

b. wrap and throw b. Closed b. bought
 c. water sealed c. shared
d. pit privy d. others (specify)
e. others (specify)
10. Drinking Water Storage 11. Containers Used for water 12. Food storage
storage
a. Refrigerated a. Plastic pitcher a. Covered
b. Covered b. Bottles b. Uncovered
c. uncovered c. Jar, clay pots c. Refrigerator
d. Others (specify) d. Cabinet
e. Others (specify)

Home and Environment continued: (tick the appropriate box)

13. Cooking facilities 14. Common pests found at home 15. Are there breeding sites for these
pests?
a. Gas stove a. Ants a. YES
b. Electric stove b. Flies b. NO
c. charcoal c. Bed bugs Note: specify what pest
d. wood d. Rats
e. Others (specify) e. Termites
f. Mice
g. cockroaches
h. Others (specify)
16. Pets/animals kept in the 17. Are there accident hazards
home/yard present in the home?
a. a. YES
b. b. NO
c. NOTE: specify what hazard
d.
e.
f.
g.

IX. HEALTH AND HEALTH PRACTICES

1. Common illnesses suffered in the last 6 months and the treatment applied
COMMON ILLNESS TREATMENT APPLIED
A.
B.
C.
D.

Health and health practices continued: (tick the appropriate box)

2. Whom do you consult for the health-related 3. For problems other than health, whom do you consult?
problems?
a) Manghihilot a) Family members
b) Midwife b) Friends
c) Doctor c) Priest/ Church leader
d) Albularyo d) Relatives
e) Nurse e) Barangay officials
f) Others (specify) f) Others (specify)
4. Immunization status of family members

Type of immunization None Incomplete Complete

a) EPI for under five children
b) COVID vaccines for ages 5 years and older
c) Others (specify)
5. Physical and mental health
Does members of the family have had adequate…
YES NO
a) Rest and sleep
b) Exercise
c) Relaxation activities
d) Stress management activities
 X. ENVIRONMENT
1. Environment
a) Kind of neighborhood

b) Social and health facilities available

c) Communication and transportation facilities

2. Awareness of community Organization
a) Are members of the family aware of existing YES NO
organizations in the community?
b) Provide names of organizations that you know Are you a member of this Are you aware of the
organization? organization’s activities and
projects?
YES /NO YES/NO
1.
2.
3.
4.
5.
c) How are you involved in its activities? (tick the box if answer is “yes”)
1. Attend meetings
2. Give donations
3. Planning
4. Implementation
5. Evaluation
6. Others (specify)
d) Name 5 formal and non-formal leaders of the community whom you think can lead the people
1.
2.
3.
4.
5.

4. Immunization status of family members

Type of immunization None Incomplete Complete

d) EPI for under five (if the child received one dose
of BCG, three doses each of
 children OPV, DPT, and Hepatitis B
vaccines, and one dose of
measles vaccine before
reaching one year of age)
1. Name of child
2. Name of child
3. Name of child
e) COVID vaccines for
ages 5 years and
older
Ages 5-11 (incomplete if with one (complete if with 2 doses of
1. Name vaccine shot) vaccines)
2. Name
3. Name
Ages 12-17 (Incomplete if with no (if with 2 shots + 1 booster
1. Name booster shot) shot)
2. Name
3. Name
Ages 18 and above (complete if with 2 booster
1. Name shots)
2. Name
3. Name
f) Others (specify)

1. Name
2. Name
3. Name