Family Health Record

8/9/2019 Family Health Record

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Family Health Record

Head of the Family : _______________________________ Family No. :____________Address : _______________________________ Zone :

____________Date : _______________________________

I. Assessment of the Family, Home & Environmental Conditions:

A. Family Type:( ) Nuclear ( ) Extended ( ) Matriarchal ( )

PatriarchalB. Members of the Household:

Family Member Relation toHead

Sex

Age

Birthday MaritalStatus

Religion

HighestEducationCompleted

Occupation# Name M D Y Type

ofWork

Place Income

C. General Family Relationship/Dynamics:

Criteria Status AdditionalInformation

D. Home & Environment

1. Homea. Ownership: ( ) Owned ( ) Rented ( ) Rent-freeb. Construction materials used:

( ) Light ( ) Mixed ( ) Strongc. No. of rooms used for sleeping:__________d. Lighting Facilities:

( ) Electricity ( ) Kerosene ( ) others:Specify_______

e. Appliances owned:____________________________________________

f. General Sanitary Condition;_____________________________________

Common household pests found athome______________________

Are there breeding sites of insects/rodents, etc. present?( ) Yes ( ) none

2. Drinking Water Supply( ) Private ( ) Public

a. Source: ( ) Pump well ( ) Deep well ( ) NAWASA( ) Distilled/Purified

b. Distance from house:___________________


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c. Storage:( ) None (direct from faucet or pipe)( ) Large covered container with faucet( ) Large uncovered container with faucet( ) Others, specify:___________________

3. Kitchena. Type of food:

Breakfast:( ) Meat & Rice ( ) Mixed( ) Vegetable & Rice ( ) Processed food

with Rice( ) Others:______

Lunch:

( ) Meat & Rice ( ) Mixed( ) Vegetable & Rice ( ) Processed food


Supper:

( ) Meat & Rice ( ) Mixed( ) Vegetable & Rice ( ) Processed food


b. Cooking Facility:( ) Electric Stove ( ) Firewood( ) Gas stove ( ) Charcoal

c. Food Storage:( ) Refrigerator ( ) Kitchen ware( ) Pots/Pans ( ) Cabinet

d. Sanitary Condition:______________________________e. Drainage Facility:

( ) Open Drainage( ) Blind Drainage( ) None

4. Waste Disposal

a. Refuse & GarbageContainer ( ) Covered ( ) open ( ) NoneMethod of Disposal

( ) Hog feeding ( ) Open Burning( ) Open Dumping ( ) Garbage Collection( ) Burial in pit ( ) Composting( ) others:____________________

b. ToiletType ( ) None ( ) Pail system

( ) Over hung latrine ( ) Antipolo( ) Open pit privy ( ) Water-sealed Latrine( ) Close pit privy ( ) Flush type( ) Bored-hole latrine ( )

others:________________Distance from house:_____________________Sanitary condition:_______________________

5. Domestic Animals

Kind Number Where kept


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E. The Community in General

a. General Sanitarycondition:_________________________________________

b. Housing Congestion: ( ) yes ( ) Noc. Are there Accident hazards present? ( ) Yes ( ) Nonec. Availability of Health Care Services (Describe briefly)

______________________________________________d. Distance of house from nearest health center facilities

______________________________________________e. Nearest Government Hospital

______________________________________________f. Nearest Recreational Park:

______________________________________________g. Nearest Public School:______________________________________________

II. Health Assessment and StatusA. Family Health Status/Health History

( ) Diabetes Mellitus ( ) Tuberculosis( ) Hypertension ( ) Hepatitis( ) Cancer ( ) Human Immunodeficiency Virus( ) Asthma ( ) Cardiovascular Disease( ) Cerebrovascular ( ) Malnourished

Accidents ( ) Others:_____________________________B. Lifestyle

( ) Sedentary( ) Alcohol Drinker( ) Smoker

C. Accidents:

HouseholdMember Name of Accident When Where Remarks

D. Health & Health Practices

a. To whom you consult for health related problems?( ) Manghihilot ( ) Albularyo ( )

Others:__________( ) Midwife ( ) Nurse( ) Doctor ( ) Health Center

b. for problems other than health, whom do you consult?( ) family members ( ) relatives ( )

others:__________( ) friends ( ) Barangay Officials

E. Childhood Immunization:


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F. Pregnancy Profile:

1. Baseline Data

HHM# Age BloodPressure

Weight LMP EDC AOG Gravida Para

2. ImmunizationHHM# TT1 TT2 TT3 TT4 TT5

3. Common Pregnancy Discomforts:( ) Nasal Stuffiness ( ) Shortness of Breath( ) Nausea/vomiting ( ) Heartburn( ) Feeling Faint ( ) Backache

( ) Frequent Urination ( ) Constipation & Hemorrhoids( ) Increase Vaginal Discharge ( ) Trouble sleeping

4. Common Danger Signs:( ) Fever ( ) Sudden weight gain( ) severe vomiting ( ) Edema on hands & face( ) Headache ( ) Sudden gush of fluid

( ) Blurred vision( ) pain in Epigastric region

5. Family Planning: ( ) Natural ( ) Artificial ( ) None

HHM# Withdrawal

RhythmMethod

Abstinence

Pills DepoProvera

Condom IUD

Name ofChild

Age BCG Hepa B DPT OPV Measles Others


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6. Suggested Topics for Health Education:

( ) Family Planning ( ) Tuberculosis( ) Dengue Prevention ( ) Malaria

( ) Proper Garbage Disposal ( ) Diarrhea( ) Malaria ( ) Cholera( ) Rabies

III. Awareness of Community Organization:

A. Are you aware of existing organizations in the community?( ) Yes ( ) No

B. Name all organizations you know:

No.

Name of Organization

C. Are you a member of any of these organizations?( ) Yes ( ) No

D. Are you aware of its activities and projects?( ) Yes ( ) No

E. How are you involved in its activities?( ) attend meetings ( ) give donations

( ) planning ( ) Evaluation( ) implementation ( ) Others:__________

F. Name 5 formal and non formal leaders of the community whom you thinkcan lead the people.

No. Name of formal/non formal

Assessed by:

_____________________________ Signature over printed name

Checked by:

_______________________________signature over printed name

COMMUNITY FAMILY DIRECTORY

AssignedHousehol

dNumber

Head of theFamily

HouseNumber

Zone Birthday


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HOUSEHOLD FAMILY DIRECTORY


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Head of the Family : Zone :Household Number : Date :

Household Member

No.

Members of the Family Birthday

HOUSEHOLD FAMILY DIRECTORY

Head of the Family : Zone :Household Number : Date :

Household MemberNo.

Members of the Family Birthday


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PREGNANCY WATCH

HouseholdNumber

Name Last MenstrualPeriod

Age ofGestation

Expected Dateof Delivery


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BLOOD PRESSURE MONITORING

Date Name of

Client

Age Blood

Pressure

Signature Remarks


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SERVICE & PROGRESS NOTE

Name of Client : AssignedHousehold No.:Zone :

DATE HEALTHCONDITIONS/

NURSINGPROBLEMS

NURSINGOBSERVATIONS,

ACTIONSTAKEN/PROGRESS/OUTC

OME

SIGNATURE

SERVICE & PROGRESS NOTE


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Name of Client : AssignedHousehold No.:Zone :

DATE HEALTHCONDITIONS/

NURSINGPROBLEMS

NURSINGOBSERVATIONS,

ACTIONSTAKEN/PROGRESS/OUTC

OME

SIGNATURE

RELATED LEARNING EXPERIENCEATTENDANCE

Group : Date :Area : Clinical Instructor:

Name Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Remarks

________________________________Signature of Clinical

Instructor


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RELATED LEARNING EXPERIENCEATTENDANCE

Group : Date :Area : Clinical Instructor:

Name Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Remarks

________________________________Signature of Clinical

Instructor

Family Health Record

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