JG Respo
JG Respo
JG Respo
/avg 1
III. SOCIO-ECONOMIC AND CULTURAL FACTORS
A. Income
12. Neighborhood
/ Congested Slum Other
13. Availability of Health Care Facility
/avg 2
Describe briefly: near to us
14. Garbage disposal
Dumped at street corner / Picked up by garbage collector
Buried Burned then buried Others(specify)
Vaccinations
/avg 3
PART B.
DETERMINE AT LEAST 3 FAMILY HEALTH PROBLEMS. IF NONE, DETERMINE THE FAMILY’S PROMOTIVE OR PREVENTIVE
PRACTICES.
FAMILY HEALTH PROBLEMS. / TYPOLOGY OF HEALTH PROBLEM
(WELLNESS STATE , HEALTH DEFICIT,HEALTH THREAT,
(IF NONE, FAMILY’S PROMOTIVE OR FORESEEABLE CRISIS)
PREVENTIVEPRACTICES.)
2.
PART C.
DO THE SCALING OF THE 3 IDENTIFIED HEALTH PROBLEMS OR PROMOTIVE PRACTICES OF THE FAMILY.
HEALTH PROBLEM 1:
MODIFIABILITY OF THE
PROBLEM
PREVENTIVE POTENTIAL
SALIENCE
TOTAL
/avg 4
HEALTH PROBLEM 2:
MODIFIABILITY OF THE
PROBLEM
PREVENTIVE POTENTIAL
SALIENCE
TOTAL
HEALTH PROBLEM 3:
MODIFIABILITY OF THE
PROBLEM
PREVENTIVE POTENTIAL
SALIENCE
TOTAL
Surveyed by _________________________
Date ______________________________
/avg 5