Client’s Name: Occupation:

Age: Educational attainment:

Sex: Relationship to the head of the family:
I. Initial Data Base of the Family

Name Relation Sex Age Civil Position in the Place of Residence

to Head Status family

1.)

2.)

3.)

4.)

5.)

6.)

Length of residency:
Type of family structure:
No. of children:
Dominant family members in terms of decision making:
II. Socio economic Data

Members of the Occupation Income Place Educational Ethnic Religion

family of Attainment background
work

Joined monthly income:

Below 2000php ( ) 3000php-5000php ( ) 5001php-8000php ( ) more than 8000php ( )

B. Basic Expenditures
1. Food daily
Below 50php ( ) 50php-75php ( ) More than 80php ( )
2. Clothing no. of times of buying in a year
Once ( ) Twice ( ) Thrice ( ) more than ( )
3. Housing
Water ( ) Electricity ( ) Telephone ( )
4. Schooling
Public ( ) Private ( )
5. Others:
C. Nutrition

1. Food preference
Fish ( ) Fruit/Vegetable ( ) Meat ( )
2. Common pair
Rice and eggs ( ) Rice and noodles ( ) Rice and sardines ( ) Others:

III. Housing and environmental condition

A. House
1. Type of housing
Concrete ( ) Wood ( ) Mixed ( ) Makeshift ( )
Others:
2. Ownership
Owned ( ) Rented ( ) Rent-free ( ) Others:
3. No. of rooms for sleeping:

4. Ventilation:
Poor ( ) Good ( )
5. Lighting facilities
Electricity ( ) Kerosene ( ) Others:
6. General Sorroundings
Clean ( ) Dirty ( )
B. Source of water supply
Artesian well ( ) Deep well ( ) NAWASA ( ) Water district ( )
C. Storage of drinking water
Refrigerated ( ) Covered ( ) Uncovered ( )
D. Kitchen
Electric stove ( ) Gas stove ( ) Charcoal/Firewood ( )
E. Drainage
Open ( ) Blind ( ) None ( )
Sanitary observations:
F. Containers used: Plastic ( ) Jars ( ) Others:
G. Toilet facilities:
Owned ( ) Shared ( ) Communal ( )
Sanitary: Flush ( ) Close privy ( ) Water sealed ( )
Unsanitary: Ballot system ( ) Antipolo ( ) Cat hole ( ) Others:
H. Waste Disposal:
Hog feeding ( ) Collected ( ) Composting ( ) Open dumping ( ) Burned ( )
Burial inpit ( ) Garbage cans ( ) Others:

I. Drainage Systems(Residential Drainage System, Surface Drainage, Subsurface Drainage, Slope Drainage)
____________________________________________
J. Food Storage
Covered ( ) Refrigerated ( ) Uncovered ( )
K. Presence of Animals
Dogs ( ) Cats ( ) Pigs ( ) Others:
L. Backyard Gardening
Vegetables ( ) Herbal ( ) Fruit Bearing ( ) Others:
M. Community Observations
i. Sanitary Conditions:
ii. House: Slum ( ) Congested ( ) Squatters ( )
iii. Presence of breeding sites for vectors:
iv. Health Facilities:
v. Recreational Facilities:
vi. Distance of the house to nearest health care facility:
 IV. Health Status of each family member
1. Medical History, belief medical practices:
S:

O:

2. Nutritional assessment
a. Anthropometrics measurement: weight, height, MUAC
S:

O:

b. Dietary history of food intake

S:

O:

c. Eating, feeding habits

S:

O:

3. Developmental assessment of infants toddlers and pre-schoolers

S:

O:

4. Physical assessment wether indicated by diagnosis

S:

O:
5. Result of laboratory/diagnostic procedures supportive by physical assessment findings
S:

O:

Values and Practices for health promotion

1. Immunization status of family members

2. Use of preventive health services

3. Adequacy of rest and sleep, exercise, relaxation activities, stress management practices