University of San Carlos
School of Health Care Professions
Department of Nursing
Assessment Tool (Individual/ Family)
Community Health Nursing
Date of Assessment:
Head of the Family:
Source of Income:
Monthly Income:
Water Source:
Source of Electricity:
Family Members
Name Age/Religion
Occupation
Education
status
Health
condition
Medications
taken if any
Hereditary
Diagnosed
Type of family:______________________
Family Disease( Hereditary and diagnosed by a physician)____________________________________
Description of the House/Community:(Narrative)
Priority Problem Identified(Please check:
______Health Threat
______Health Deficit
______Foreseeable crisis
Description of the Problem Identified:____________________________________________________
Community Rolet of te family members: (Please Check and specify name)
______ Official (Barangay)__________
______registered Voter
______Tanod
______BHW
______Church Leader
______Others
Where to seek consultation in case of poor health conditions: Please check
______Health Center
______Private clinics
______Hospitals
______others please specify:______________________________________________
How many Times of visit for consultation:__________
Environmental Concerns:
Environmental Hazards:
Common practices related to environmental issues:
Waste Disposal: is the family aware of the schedule of waste disposal?