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FAMILY ASSESSMENT FORMAT - CHN practical

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  COMMUNITY HEALTH NURSINGPRACTICAL - FAMILY ASSESSMENT FORMATPrepared by Dr. Sudhadevi SadanandanFAMILY ASSESSMENT1. Identification DataName of the Student : __________________________Roll Number : __________________________Course / Semester : __________________________Name of the Institution : __________________________Date of Home Visit : __________________________Area / Place (Urban / Rural) : __________________________Name of Head of the Family : __________________________Address : __________________________Religion : __________________________Type of Family : __________________________Total Number of Family Members : __________________________Socio-economic Status : __________________________Source of Information : __________________________2. Family ProfileAge and Sex of Head of Family : __________________________Occupation : __________________________Monthly Income : __________________________Nearest Health Facility : __________________________Emergency Facility (108) : __________________________
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  3. Family Composition( Table form )S. No. – Name – Age – Sex – Relationship – Education – Occupation – Health Status4. Family Tree (Genogram)A simple family tree showing relationships among family members is drawn.5. Housing & Environmental ConditionsType of House : __________________________Ownership : __________________________Number of Rooms : __________________________Ventilation : __________________________Lighting : __________________________Source of Water Supply : __________________________Toilet Facility : __________________________Drainage System : __________________________Waste Disposal Method : __________________________Surroundings : __________________________6. Dietary PatternType of Diet : __________________________Number of Meals per Day : __________________________Food Habits : __________________________Nutritional Adequacy : __________________________7. Personal Hygiene PracticesBathing Habits : __________________________Hand Washing Practices : __________________________
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  Oral Hygiene :__________________________8. Health Status of Family MembersPresent Illness : __________________________Past Illness : __________________________Chronic Illness (if any) : __________________________Communicable Diseases : __________________________9. Immunization StatusDetails of immunization of children (if applicable) are noted.(If no children below five years, mention Not applicable.)10. Family Health PracticesDietary and lifestyle practices of the family : __________________________Utilization of health services : __________________________11. Observation & InferenceThe overall assessment indicates the family’s health status and contributing factors.12. Identified Health Problems1.2.13. Priority Needs1.2.
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  14. Health Education1.2.3.4.56.15.ConclusionFamily assessment helped in identifying health problems and planning appropriate nursingcare.📌Community health nursing care planPlease refer the following link:👉[https://share.google/er7fM2tnjnOzwgwwd]