FAMILY SERVICE AND PROGRESS RECORD

HEAD OF THE FAMILY:

FAMILY NUMBER:
ADDRESS:

I. Assessment of the Family, Home and Environmental Conditions:

A. Members of the Household

RELATIO HIGHEST REMARKS/

S
N TO MARITAL EDUC DATE
FAMILY MEMBER E BIRTHDATE OCCUPATION
THE STATUS COMPLETED ENTERED
X
HEAD

N Name Mont Year Type of work Place

o h

10

B. Home and Environment

Date Assessed:

1. Home

a. Ownership ( ) Owned ( ) Rented ( ) Rent-Free

b. Construction Materials used: ( ) Light ( ) Mixed ( ) Strong
 c. Number of rooms for sleeping:
d. Lighting facilities ( ) Electricity ( ) Kerosene ( ) Others Specify
e. General sanitary condition:

2. Drinking water supply

Source: ( ) Private ( ) Public Potability:

Distance from house:
Storage: ( ) None (Direct from faucet or pipe)
( ) Large covered container with faucet
( ) Large uncovered container without faucet
( ) Others, Specify ____________________________________________________

3. Kitchen
Cooking facility: ( ) Electric stove ( ) Gas Stove ( ) Firewood/charcoal
Sanitary condition: Good
Drainage Facility: ( ) Open drainage ( ) Blind drainage ( ) None

4. Waste Disposal

a. Refuse and Garbage

Container: ( ) Covered ( ) Open
Method of disposal:
( ) Hog feeding ( ) Composting
( ) Open dumping ( ) Open burning
( ) Burial in pit ( ) Others, specify: Garbage Collection
b. Toilet
Type: ( ) None ( ) Pail system
( ) Overhung latrine ( ) Antipolo
( ) Open pit privy ( ) Water sealed latrine
( ) Closed pit privy ( ) Flush type
( ) Bored-hole latrine
( ) Others, specify: ______________________
Distance from house:
Sanitary condition:
5. Domestic Animals:

KIND NUMBER WHERE KEPT

6. The Community in General

a. General sanitary condition:

b. Housing congestion: ( ) Yes ( ) No
c. Recreational Facilities:
d. Availability of health care services (describe briefly):
e. Distance of house from nearest health care facility:
 Problem Sheet

HEALTH DATE
NURSING SUPPORTING
CONDITIONS AND
PROBLEMS DATA CUES IDENTIFIED RESOLVED
PROBLEMS

Nursing Care Plan

HEALTH EVALUATION
CONDITIONS AND
OBJECTIVE OF PLAN OF OUTCOME
PROBLEMS AND METHOD /
NURSING CARE INTERVENTION CRITERIA/
FAMILY NURSING TOOLS
PROBLEMS INDICATORS

Service and Progress Notes

 NURSING INTERVENTIONS,
DATE NURSING PROBLEMS SIGNATURE
ACTIONS AND PROGRESS

FAMILY SERVICE AND PROGRESS RECORD

HEAD OF THE FAMILY:
FAMILY NUMBER:
ADDRESS:

II. Assessment of the Family, Home and Environmental Conditions:

C. Members of the Household

RELATIO HIGHEST REMARKS/

S
N TO MARITAL EDUC DATE
FAMILY MEMBER E BIRTHDATE OCCUPATION
THE STATUS COMPLETED ENTERED
X
HEAD

N Name Mont Year Type of work Place

o h

10

D. Home and Environment

Date Assessed:

2. Home

f. Ownership ( ) Owned ( ) Rented ( ) Rent-Free

g. Construction Materials used: ( ) Light ( ) Mixed ( ) Strong
h. Number of rooms for sleeping:
i. Lighting facilities ( ) Electricity ( ) Kerosene ( ) Others Specify
 j. General sanitary condition:

2. Drinking water supply

Source: ( ) Private ( ) Public Potability:

Distance from house:
Storage: ( ) None (Direct from faucet or pipe)
( ) Large covered container with faucet
( ) Large uncovered container without faucet
( ) Others, Specify ____________________________________________________

3. Kitchen
Cooking facility: ( ) Electric stove ( ) Gas Stove ( ) Firewood/charcoal
Sanitary condition: Good
Drainage Facility: ( ) Open drainage ( ) Blind drainage ( ) None

4. Waste Disposal

c. Refuse and Garbage

Container: ( ) Covered ( ) Open
Method of disposal:
( ) Hog feeding ( ) Composting
( ) Open dumping ( ) Open burning
( ) Burial in pit ( ) Others, specify: Garbage Collection
d. Toilet
Type: ( ) None ( ) Pail system
( ) Overhung latrine ( ) Antipolo
( ) Open pit privy ( ) Water sealed latrine
( ) Closed pit privy ( ) Flush type
( ) Bored-hole latrine
( ) Others, specify: ______________________
Distance from house:
Sanitary condition:

5. Domestic Animals:
 KIND NUMBER WHERE KEPT

6. The Community in General

f. General sanitary condition:

g. Housing congestion: ( ) Yes ( ) No
h. Recreational Facilities:
i. Availability of health care services (describe briefly):
j. Distance of house from nearest health care facility:

Problem Sheet
 HEALTH DATE
NURSING SUPPORTING
CONDITIONS AND
PROBLEMS DATA CUES IDENTIFIED RESOLVED
PROBLEMS

Nursing Care Plan

HEALTH EVALUATION
CONDITIONS AND
OBJECTIVE OF PLAN OF OUTCOME
PROBLEMS AND METHOD /
NURSING CARE INTERVENTION CRITERIA/
FAMILY NURSING TOOLS
PROBLEMS INDICATORS

Service and Progress Notes

DATE NURSING PROBLEMS NURSING INTERVENTIONS, SIGNATURE

 ACTIONS AND PROGRESS

FAMILY SERVICE AND PROGRESS RECORD

HEAD OF THE FAMILY:

FAMILY NUMBER:
ADDRESS:

III. Assessment of the Family, Home and Environmental Conditions:

E. Members of the Household

RELATIO HIGHEST REMARKS/

S
N TO MARITAL EDUC DATE
FAMILY MEMBER E BIRTHDATE OCCUPATION
THE STATUS COMPLETED ENTERED
X
HEAD

N Name Mont Year Type of work Place

o h

10

F. Home and Environment

Date Assessed:

3. Home

k. Ownership ( ) Owned ( ) Rented ( ) Rent-Free

l. Construction Materials used: ( ) Light ( ) Mixed ( ) Strong
m. Number of rooms for sleeping:
n. Lighting facilities ( ) Electricity ( ) Kerosene ( ) Others Specify
o. General sanitary condition:
2. Drinking water supply

Source: ( ) Private ( ) Public Potability:

Distance from house:
Storage: ( ) None (Direct from faucet or pipe)
( ) Large covered container with faucet
( ) Large uncovered container without faucet
( ) Others, Specify ____________________________________________________

3. Kitchen
Cooking facility: ( ) Electric stove ( ) Gas Stove ( ) Firewood/charcoal
Sanitary condition: Good
Drainage Facility: ( ) Open drainage ( ) Blind drainage ( ) None

4. Waste Disposal

e. Refuse and Garbage

Container: ( ) Covered ( ) Open
Method of disposal:
( ) Hog feeding ( ) Composting
( ) Open dumping ( ) Open burning
( ) Burial in pit ( ) Others, specify: Garbage Collection
f. Toilet
Type: ( ) None ( ) Pail system
( ) Overhung latrine ( ) Antipolo
( ) Open pit privy ( ) Water sealed latrine
( ) Closed pit privy ( ) Flush type
( ) Bored-hole latrine
( ) Others, specify: ______________________
Distance from house:
Sanitary condition:

5. Domestic Animals:

KIND NUMBER WHERE KEPT

 6. The Community in General

k. General sanitary condition:

l. Housing congestion: ( ) Yes ( ) No
m. Recreational Facilities:
n. Availability of health care services (describe briefly):
o. Distance of house from nearest health care facility:

Problem Sheet

HEALTH NURSING SUPPORTING DATE

 CONDITIONS AND IDENTIFIED RESOLVED
PROBLEMS DATA CUES
PROBLEMS

Nursing Care Plan

HEALTH EVALUATION
CONDITIONS AND
OBJECTIVE OF PLAN OF OUTCOME
PROBLEMS AND METHOD /
NURSING CARE INTERVENTION CRITERIA/
FAMILY NURSING TOOLS
PROBLEMS INDICATORS

Service and Progress Notes

NURSING INTERVENTIONS,
DATE NURSING PROBLEMS SIGNATURE
ACTIONS AND PROGRESS