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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
with Rice( ) Others:______
Supper:
( ) Meat & Rice ( ) Mixed( ) Vegetable & Rice ( ) Processed food
with Rice( ) Others:______
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