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
