COLLEGE OF NURSING
CARLATAN, SAN FERNANDO CITY, LA UNION
FAMILY ASSESSMENT GUIDE
COMMUNITY NEEDS ASSESSMENT /MINIMUM BASIC NEEDS (MBN) FOMR
Date: January 21 , 2022
Family Name: F / Catbangen (Barangay)
I. Demographic Data
Household Number: 3 Barangay House Number: 675 0
II. FAMILY DATA
Length of Residency: 30 years Place of origin: San Fernando City, La Union
Family Size: 3 Religion: Roman Catholic
Husband’s name: ASF Wife’s name: GBF
FAMILY MEMBER’S CHART
POSITION RELATIONSHIP
CIVIL
FAMILY MEMBERS AGE SEX
STATUS
IN THE TO THE FAMILY EDUCATIONAL OCCUPATION
FAMILY HEAD ATTAINMENT
1. A.F 49 M Married
Head/ College Tricycle
Father graduate operator
2. G.F 56 F Married Mother Husband
College
Housewife
graduate
3. A.J.F 19 M Single Son Father College Student
4.
5.
6.
7.
8.
III. FAMILY CHARACTERISTICS
Type of Family Structure
A. Extended: ____ B. Matriarchal: _____ C. Dominant Family Member: ___
D. Nuclear: E. Patriarchal: _____
General Family Relationship/Dynamics
CRITERIA STATUS ADDITIONAL
INFORMATION
Observable conflicts between family Conflict between
Being observed
members parents and child.
Characteristics of communication Have freedom of All family members
expression and good talks to each other and
communication feel free to express.
Interaction patterns among members All family members able
Open
to share thoughts.
Family Dietary Habits
What did you eat yesterday? (24 hours dietary recall)
Breakfast: 2 cups of fried rice, 1 boiled egg, 3 slice of pork tocino, 1 cup of milk, 1 glass
of water and 1 slice of apple.
Lunch: 2 cup of rice, 1 serving of dinakdakan, 1 glass of orange juice, 2 glasses of
water and 1 pc. banana
Dinner/Supper: 1 cup of rice, 1 serving of pinakbet, 2 glasses of water
Monthly Family Income Source
Husband: work and business Wife: None
Others: None
below Ph 5,000_____ above PhP 20,000- 30,000 d
above Ph 5,000-10,000____ above PhP 30,000- 40,000___________
above Ph 10,000- 15,000___ above Ph 40,000- 50000 __________
above Ph 15,000-20,000____ above Ph 50,000
FAMILY HEALTH STATUS/HEALTH HISTORY
Father: DIABETES
Mother: NONE
Children/s: Had history of asthma
FELT FAMILY NEEDS (Identify and rank according to priority)
1. Water 5. Job
2. Food 6. Education
3. Health Services 7. Transportation
4. Money 8. Security
IV. HOME AND ENVIRONMENT
A. Is your lot owned? YES _________ NO_________________
B. Is your house owned? YES__________ NO_________________
C. Type of Housing materials? wood ____________ concrete: ___________
Mixed: ______ makeshift: _____ others, specify__________________________
D. Is the living space adequate? YES_____________NO____________________
E. What are the appliances owned by the family? TV, refrigerator,electric fan, aircon, oven,
gas stove, rice cooker, blender, washing machine, water despenser, coffee maker,
printer, computer
F. Type of Garbage Disposal
__________Collected __________burning
__________Waste segregation __________burying
__________ feeding animals __________throw in the river
__________open dumping __________ others, specify _____
G. Type of waste Disposal
__________Flush __________ water-sealed (private)
__________wrap and throw __________ pit-privy
__________dig and bury _________water-sealed (communal)
Others,specify_____________________________________________________
H. Types of Drainage System __________Open ____________ Closed
I. Source of water ___________owned _______________bought __________shared
Others, specify_________________________________________________________
J. Drinking water storage
___________refrigerated _________Covered Uncovered: _____________
K. Container used
____________Plastic pitchers _____________jars /clay pots
____________bottles _____________others,specify
L. Food Storage/ Cooking facilities
___________Covered ______________Uncovered ___________Stove
___________Refrigerator ______________Cabinet __________Pots/pans
M. Common Household pests found at home
1. Cockroach 2. Rat 3. ___________________
2. Are there breeding sites of insects, rodents present?
YES__________NO________
3. Pet/ Animals kept in the home/Yard Dogs and cat
4. Are there hazards present? YES _____________NO_______________
V. HEALTH and HEALTH PRACTICES
A. Common illnesses encountered for the last 6 months and treatment applied
____________ diarrhea _______ colds _____________cough
____________influenza_______stomach pains_______headache
____________toothache______Hypertension________Diabetes
____________gastritis ________ __________________others, specify
B. Whom do you consult for health-related problems?
___________” Manghihilot “ __________midwife
___________Doctor __________BHW
___________quack doctor/ albularyo __________Clinic
___________self-medication others, specify___________________________
C. For problems other than health, whom do you consult?
___________ family members ____________relatives
___________friends __________barangay officials
___________priest Others, specify ______________________________
D. Immunization status of family members: complete
E. Have you had adequate?
_____1. Rest YES____ NO______
_____2. Exercises YES____ NO______
_____3. Relaxation Activities YES____ NO______
_____4. Stress management YES____ NO______
VI. KIND OF NEIGHBOORHOOD
1. Kind of Neighborhood Urban
2. Social and Health facilities BHC,CHO,schools,church,private and
available public hospitals,clinics
3. Communication and Cellphones,Private
transportation vehicle,tricycle,motor,
V. AWARENESS OF COMMUNITY ORGANIZATION
A. Are you aware of the existing organizations in the community? YES______ NO_________
B. Name all the organizations you know? LINK, Sangguniang kabataan, senior citizens
C. Are you member of these organizations? YES_______ NO_____________
D. Are you aware of its activities and projects? YES_____ NO_____________
E. How are you involved in its activities?
_______1. Attend meeting _______4. Give donations
_______2. Planning _______5. Evaluation
_______3. Implementation others, specify_____________________
F. Name five (5) formal and non-formal leaders of the community whom you think can lead the
people?
POSITION
1. Mayor Herminigildo Gualberto CITY MAYOR
2. Dr. Lilibeth Hipol PRIVATE DOCTOR
3.Hon. Jeffrey A. Apilado BARANGAY CAPTAIN
4. Ms. Precious Whites PRESIDENT SK FEDERATION
5. Atty. Ernesto V. Rafon CITY COUNCILOR
Interviewer: FRONDA, ARON JOHN B.
Student Nurse II Section: BSN-II SCHOENHOFER
Clinical Instructor: MRS. MARIAH DELILAH TURZAR
