Family Assessment Tool 2022 1
Family Assessment Tool 2022 1
Family Assessment Tool 2022 1
COLLEGE OF NURSING
FAMILY ASSESSMENT TOOL
Address: _____________________________________________________________________________________
I. DEMOGRAPHIC DATA
Household Number (number of families in the house) ____________________
Family Characteristics
Type of Family Structure
A. Extended _____ C. Nuclear ____
B. Matriarchal ____ D. Patriarchal__
Relationship of members
1. Husband and Wife _________________________________________
2. Father and Children ________________________________________
3. Mother and children ________________________________________
4. Children to children ________________________________________
Total monthly family income source: ( ) below 5,000 pesos ( ) above 5,000 – 10,000 ( ) above 10,000 – 15,000
( ) above 15,000 – 20,000 ( ) above 20,000 – 30,000 ( ) above 30,000 – 40,000 ( ) above 40,000
4. Waste disposal
a. Refuse and garbage method of disposal: ( ) garbage collection ( ) open burning ( ) composting
( ) open dumping ( ) burial in pit ( ) feeding to animals ( ) others/specify _______________
b. Toilet Facilities
Type: ( ) pit privy ( ) water sealed ( ) flush
( ) flying saucer/wrap and throw ( ) others, specify _________________________
Location: ( ) inside the house ( ) outside the house
Sanitary condition: _____________________________________________________________________
5. Domestic animals
Kind Number Where Kept
B. Past significant illnesses and accidents of each member (for the past 2 years)
Name of Family Member Past Illness/Accidents
1.
2.
3.
4.
5.
F. Name 5 formal and nonformal leaders of the community whom you think can lead the people.
1.
2.
3.
4.
5.