Assessment Tool

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ASSESSMENT TOOL FOR COMMUNITY HEALTH NURSING A. Family structure and characteristics Name: Age: Sex: Civil Status: Educational Attainment: Occupation: Position in the Family: Type of family structure in the household Members involved in terms of decision--making (especially in health)? How do you solve conflicts at home or in the community?

B. Socio-economic and cultural characteristics 1. Income expenses: Occupation: 2. Ethnic background and religious affiliation 3. Significant others—role(s) they play in family’s life

4. Organizations in the community:

C. Home and environment 1. Housing i. Adequacy of living space ii. Sleeping arrangement iii. Presence of accident hazards iv. Food storage and cooking facilities v. Water supply—source, ownership, potability vi. Toilet facility—type, ownership, sanitary condition vii. Garbage/ refuse disposal—type, sanitary condition viii. Drainage system—type, sanitary condition 2. Kind of neighborhood (e.g. congested, slum) 3. Social and health facilities available 4. Communication and transportation facilities used

D. Health status of each family member 1. Current illnesses in the past: 2. Nutritional assessment (specially for vulnerable or at risk members) Usual food intake:

3. Risk factors Heredofamilial disease: Sedentary lifestyle: Smoking YES [ ] NO [ ] If yes, How often?: Alcohol drinking YES [ ] NO [ ] If yes, How often?:

E. Values, habits, practices on health promotion, maintenance and disease prevention. Examples include: 1. Immunization status of family members

2. Healthy lifestyle practices. Specify. 3. Adequacy of: i. Rest and sleep ii. Exercise/activities iii. Use of protective measures Use of mosquito nets YES [ ] NO [ ] Use of insect repellants YES [ ] NO [ ] Use of slippers YES [ ] NO [ ] iv. Relaxation and other stress management activities

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