ASSESSMENT TOOL

I. GEOGRAPHIC CHARACTERISTICS
Name of the locality or area
Nearby:
___ School
___ Hospital
___ Mall/Grocery store
___ Church

II. DEMOGRAPHIC CHARACTERISTICS
a) No. of members of the family
b) No. deaths in the family
c) Classification
d) Income
e) Religion
f) Language
g) Special Health risk groups
III. HOME & ENVIRONMENT CHARACTERISTICS
a) House :
No. Floors
Ownership
Construction materials used
Type
No. of rooms

b) House Facilities :
Lighting facilities
Drinking water source
Potable
Distance from house
Storage
Cooking facility
Sanitary condition
Drainage Facility
Toilet type
Distance from house
Sanitary condition

c) Waste disposal
Container
Method of disposal

d) Educational opportunities
___ Schools
___ Private institution
___ College
___ Vocational institution


IV. SOCIOECONOMIC
No. of working members in the family
Employed
Underemployed
Unemployed
Monthly income
Source of income

V. CHANNELS OF COMMUNICATIONS : OFFICIAL, NON-OFFICIAL
- Common meeting places used
- Means of communications
- Media of communications

VI. RESOURCES
a) Economic resources of the family
b) Institutional resources

VII. HEALTH KNOWLEDGE, BELIEFS AND PRACTICES
- About health and disease

- Outlook on cause of disease, spread and presentation of disease

- Existing health practices related to prevention, care of some specific illness

- Superstitions related food and health practices

- Promotional health practices, food, rest, relaxation, recreation, games etc

- Attitude towards health agencies - positive or negative, Health programmes and community
organization.

VIII. HEALTH PROBLEMS AS FELT BY THE FAMILY
- Major health problem and needs

- Priority problems