APPENDIX A: FAMILY HEALTH ASSESSMENT FORM*
Family surname: Lozano
House No.: 77 Street: Grandstand Side
Barangay: San Vicente District: 5th district
Municipality/City: Urdaneta City Contact No.: 09081019843
Source(s) of Information: Mrs. Jocelyn Lozano
Data gathered by: Reyjan L. Apolonio Date: October 22,2021
Household Members:
NAME AGE RELATIONSHIP Health problems
TO HEAD OF
HOUSEHOLD
Brendo Lozano 53 Head of household none
Jocelyn Lozano 51 Spouse of head none
Lydia Lozano 75 Mother of the head none
Family Characteristics
Family Members living outside the household
Name, age, and relationship to head of household
Hannah Lozano, 22, Daughter
Location of Family member(s)
Labit West, Urdaneta City, Pangasinan
Frequency and duration of contact
Often. 1 time a week
Means of communication
Video chat and messenger
Family Mobility
Length of time at current address
10 years
Address of previous residence(s)
San Juan, San Manuel, Pangasinan
Frequency of Geographic moves
1 only
Family Dynamics
Emotional bonding of family members
Family cohesion, encouraged family members to talk each other, appreciate for one another, and
listening to everyone’s concerns.
Distribution of authority and power
Equally distributed.
Degree of individual autonomy
1. My daughter is separated with us. She’s located in another barangay.
How members communicate
“We often communicate with open and honest communication with each other “as verbalized by the
spouse of the head.
How decisions are made
Decisions are made based on values and determining the consequences of decisions.
How problems are solved
By communicating with each other calmly and putting emotions aside.
How conflict is handled
By separating the problem from the person and trying to cool off first.
Division of labor
Assembly line- have different task that needs to complete/ accomplished.
Socioeconomic and cultural characteristics
Family social integration
Language(s) or dialect(s) spoken
Tagalog and Ilocano
Literacy (ability to read and write in language(s)
Proficient level. They are able to read, write and understand written words.
Degree of social network with friends, neighbors, and other relatives
10
Network with religious organization
Through zoom, and attending actual fellowship.
Network with social organization
Social media, personal interactions
Educational experiences
Head of the family is criminology graduate, the spouse is a computer science graduate, and the
mother of the head is a culinary art graduate.
Work History
Pay roll clerk in CB Estrada
Adequacy of financial resources
Good and Stable financial resources.
Leisure time interest
Watching movies, and surfing the net.
Family neighborhood
Location (e.g., urban or rural, subdivision, slum area)
Urban
Type (e.g., residential, semi commercial)
Residential
Safety
Traffic patterns
Lighting
Security (Police or private)
Lighting
Population density (crowding)
Not crowded
Sources of pollution
Air
Water
Soil
Noise
Air, water, and soil
Family health and health behavior
Activities of daily living (how family spends a typical day)
“Meron kaming maliit na sari-sari store at computer shop, ayan ang lagi kong binabantayan araw-
araw” as verbalized by the spouse of the head.
Health history (pregnancy, illness, death within the past 5 years/health attendance
“I experience a surgery para maremove yung gallstones ko” as verbalized by the spouse of the head.
Self-care (health promotion and disease prevention)
“We always have a visit to a clinic for health check-up once a year” as verbalized by the spouse of
the head.
Risk behaviors
N/A
Health status (problems and priorities)
N/A
Home remedies
“Whenever nagkakaroon ng ubo at sipon ang asawa ko, nagtitimpla lang ako ng calamansi juice” as
verbalized by the spouse of the head.
Health care resources
Community health clinic that is near to their house.
Health workers
N/A
Health agencies
N/A
Cultural influences: values, attitudes, and beliefs about:
Spirituality:
Attending Sunday fellowship and reading bible.
Rituals (holidays and celebrations)
Fiesta ng patay, Christmas break, New Year, and Holy week.
Dietary habits
Eating more vegetables and fish. Don’t eat “dinuguan.”
Folk disease
N/A
Traditional healers
“hilot”
Family environment
Family residence
Adequacy of size:
Sufficient
Structural safety
Excellent
Water sanitation
Good. Scraping food and debris from the surface and washing and rinsing the surface.
Food preparation and storage
Excellent. “We put paper around the vegetables. We didn’t buy canned foods” as verbalized by
the spouse of the head.
Sewage
Poorly facilitated. Dirty and causes flood sometimes.
Garbage disposal
Segregated and put outside the house every Saturday.
Excreta disposal
N/A
Pest and vermin control
“We use pesticides” as verbalized.
