UNIVERSIDAD DE MANILA College of Nursing Community Health Survey Tool

I. DEMOGRAPHIC PROFILE

Family No.________

Head of the Family:________________________________ Complete Address:_____________________________________________ Father: _____________________________ Ethnic Background: _______________Place of Origin (Province) ___________________ Mother: ____________________________ Ethnic Background: _______________Place of Origin (Province) ___________________ No. of Family Members: _______________ Date Surveyed: ___________________Type of Family: ____________________________

Length of Residency:___________ Length of Residency: ___________ Length of Residency: ___________

Education (Edukasyon) Name of Household Member(s) (Pangalan ng Myembro ng Pamilya)

Age (Edad)

Occupation (Hanap Buhay)

Type (Uri) Place (Lugar) Occupational Status (Kalagayan ng Trabaho)

Gender (Kasarian)

Civil Status (Estado Sibil)

Date of Birth (mo., day, yr.) (Kapanganakan )

Religion (Relihiyon)

Relationship to the Head of the Family (Kaugnayan sa Puno ng Pamilya)

Highest Educational Attainment (Pinaka-mataas na Antas ng Edukasyong natapos)

Educational Status (Antas ng Edukasyon)

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

LEGEND:

Sex M male F female

Civil Status S Single M Married Sep Separated W Widowed CL Common Law

Religion C- Catholic INC Iglesia ni Cristo P Protestant SA 7th Day Adventist JW Jehovas Witness

EducationalStatus NF No Formal Education PS Presently Studying SS Stopped Studying CG-College Graduate VG-Vocational Graduate

OccupationalStatus E - Employed U - Unemployed SE Self-Employed

II.

SOCIOECONOMIC AND CULTURAL VARIABLES Social Variables

Economic Indicators
1. Combined Monthly family income (Buwanang kita ng pamilya) ( ) P1,000 and below ( ) P1,001 P5,000 ( ) P5,001 P10,000 ( ) P10,001 P15,000 ( ) P15,001 P20,000 ( ) P20,001 P25,000 ( ) P25,001 P30,000 ( ) P30,001 and above Other sources of Income - livelihood (Mayroon pa bang ibang pinagkukunan ng kabuhayan?) ( ) Yes ( ) No If yes, what?(kung mayroon, ano ito?) ( ) sari-sari store ( ) poultry raising ( ) livestock raising ( ) craft making ( ) Others {pls. specify}________________ Monthly expenses (Buwanang gastusin ng pamilya) ( ) P1,000 and below ( ) P1,001 P5,000 ( ) P5,001 P10,000 ( ) P10,001 P15,000 ( ) P15,001 P20,000 ( ) P20,001 P25,000 ( ) P25,001 P30,000 ( ) P30,001 and above Priority Expenditure, rank it 1 7 (1 is the highest; 7 is the lowest) ____ food (pagkain) ____ health (kalusugan) ____ house rental (upa sa bahay) ____ education (edukasyon) ____ electric consumption (bayarin sa kuryente) ____water consumption (bayarin sa tubig) ____ clothing (damit) ____ others, pls. specify

1. Communication Network
-where do you get health information? ( ) Health Center Personnel ( ) Television ( ) Radio ( ) Newspaper/ Fliers/ Posters ( ) Phone ( ) poultry raising ( ) others, please specify________________ 2. Transportation System ( ) by foot ( ) bangka ( ) vehicles ( ) by animals ( ) others, please specify________________

2.

3.

III.

ENVIRONMENTAL INDICATORS 1. Housing Condition Lot: ( ) Rented ( ) Owned ( ) others, please specify: _____________ House: ( ) Rented ( ) Owned ( ) others, please specify: _____________ No. of rooms for sleeping: __________ No. of persons per room: ___________ 2. Types of Housing materials ( ) concrete ( ) makeshift ( ) wood ( ) mixed ( ) others, please specify________________ Backyard gardening ( ) vegetables ( ) ornamentals ( ) fruit trees ( ) Herbal plants, please specify:_______________

4.

5. Resources allotted for health care (Nakalaang pondo para sa kalusugan)

( ) Yes ( ) No If yes, from where? (kung oo, galing saan?) ( ) Health Insurance ( ) SSS/GSIS ( ) Phil Health ( ) others, please specify________________ 3.

( ) others, please specify_____________________ 4. Ventilation ( ) well ventilated ( ) fairly ventilated ( ) poorly ventilated No. of windows: _______ No. of doors: _________ Lighting facilities ( ) electricity ( ) candles ( ) lamp ( ) others, please specify________________ Excreta Disposal ( ) pail system ( ) overhung latrine ( ) open pit privy ( ) closed pit privy ( ) Antipolo Type ( ) Flush type ( ) others, please specify________________ Ownership of Toilet facility ( ) private ( ) shared ( ) communal Waste Disposal ( ) composting ( ) open dumping ( ) animal feed ( ) open burning ( ) garbage collection ( ) others, please specify________________ Sewage system ( ) blind drainage ( ) open drainage ( ) none Condition of the sewage system ( ) flowing ( ) stagnant Sources of Drinking water ( ) deep well water pump ( ) natural source/s (lake, stream, river, etc.) ( ) commercially prepared ( ) local water system ( ) others, please specify________________ Storage of Drinking water ( ) bottles ( ) jar ( ) water tank ( ) drum ( ) others, please specify________________ Methods of Sanitizing water ( ) boiling ( ) filtration ( ) sedimentation ( ) others, please specify________________ Cooking Facilities ( ) gas stove ( ) electric stove

( ) firewood/ coal ( ) others, please specify________________ 15. Food storage ( ) refrigerator ( ) cabinet ( ) basket ( ) table: ___ covered ___ uncovered ( ) others, please specify________________ 16. Domestic Animals

5. 6.

7. 8.

Kind

Number

Place kept

vaccination

with

without

9. 10. 11.

12.

17. Presence of vectors (Pagkakaroon ng peste sa bahay)

( ) flies (langaw) ( ) termites (anay) ( ) rats (daga) ( ) roaches (ipis) ( ) mosquitoes ( lamok) ( ) others, pls. specify_______________________

13.

18. Ways of controlling vectors (Paraang ginagawa upang mapuksa ang mgapeste)
( ) fumigation (pag-papa-usok) ( ) fly traps ( ) screens on doors and windows ( ) insecticides ( pmatay insekto) ( ) mouse traps

14.

( ) others, pls. specify_______________________

( ) Datu ( ) Religious Leaders ( ) Social workers ( ) counselors ( ) others, please specify________________ 6. Election system ( ) Political Dynasty ( ) Kamag-anak System ( ) Appointment ( ) COMELEC ( ) others, please specify________________ 7. Political Influences ( ) Religion ( ) Popularity ( ) culture ( ) Educational Attainment ( ) political dynasty ( ) others, please specify_______________

IV.

POLITICAL/ LEADERSHIP ASPECT

1. Recognized leaders in the community ( Pangunahing taong kinukunsulta at kinikilalang

pinuno ng komunidad) ( ) Barangay Officials ( ) religious leaders ( ) elders ( ) Non- government organizations ( ) others, pls. specify___________

2. Community Program (Ano ang mga alam na programa sa komunidad)

( ) peace and order ( ) fumigation ( ) curfew ( ) tapat ko linis ko ( ) sportfest ( ) others, pls. specify aware unaware _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______________________

3. Predominant Organizations in the Community (Kilalang samahan sa komunidad)

If yes, what?(kung mayroon, ano ito?) ( ) Barangay Council ( ) Sangguniang Kabataan ( ) Couples for Christ ( ) Seniors Citizens Club ( ) other, pls. specify________________________ Member ( ) ( ) ( ) ( )

8. Social Conflict - Sources ( ) Ethnic groups ( ) Culture ( ) Religion ( ) politics ( ) Health Problems ( ) others, please specify________________ -ways in resolving conflicts in the Barangay ( ) Barangay Meeting ( ) Bahala na System ( ) House to House visit ( ) others, please specify________________ V. HEALTH ILLNESS PATTERN 1. Community health programs (programang pangkalusugan) ( ) Free consultation (libreng konsulta) ( ) Immunization (libreng Bakuna) ( ) Family Planning (Programa sa pagpapaplano ng pamilya) ( ) Pre-natal Check up (programa para sa buntis) ( ) well-baby clinic (konsulta para sa mga sanggol at bata) ( ) Others (Pls. Specify) _________________ Food usually eaten. (Madalas ng kinakain) ( ) Fish ( ) Meat Aware ______ ______ ______ ______ ______ Utilizes ______ ______ ______ ______ ______

4. Traditions celebrated/ observed in the community (Tradisyong idinaraos/ ipinagdiriwang sa

komunidad) ( ) Fiesta ( ) Holy Week ( ) others, pls. specify_________________ 5. Leadership System - Governing Authority ( ) Sitio Chairman 2. ( ) Barangay Chairman

( ) Vegetable

( ) Mixed

8. 3. Food Intake ( ) Once a day ( ) thrice ( ) twice ( ) others, please specify________________ Food storage practices.(Pangangalaga sa pagkain) ( ) table ( ) basket ( ) covered ( ) uncovered ( ) cabinet ( ) others_________________ First person consulted in times of illness (Unang taong kinukunsulta tuwing may nagkakasakit) ( ) doctor ( ) albularyo ( ) midwife ( ) relatives ( ) nurse ( ) others (pls. specify)____________ Medications taken during illness (Gamot na iniinom) ( ) prescribed ( ) dispense (health center) ( ) herbal ( ) over the counter ( ) others ( Pls. Specify)__________________ Health Practices Practice 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Praying before sleeping Praying before meals Taking bath regularly Brushing teeth Handwashing before and after eating Nail cutting Use of hygienic products Ear cleaning Regular change of clothes Exercise three times a week for 30 minutes Sleep 8-10 hours a day Recreational activities Medical checkup Dental check-up Not Practice

4.

Health Risk/s behavior ( ) smoking, who: ________________ for how long: _______________ No. of years exposed (family member): ________ No. of stick/s consumed per day:______________ ( ) using illegal drugs, who: ____________________ ( ) drinking alcohol, who: ________________ duration: _____________ ( ) eating fatty/salty foods, who: _________________ ( ) sedentary lifestyle, who: ____________________ Method of Family Planning (Pagpaplano ng pamilya) Name Age Acceptor Non- Acceptor

5.

9.

6.

7.

A. Natural ( ) rhythm ( ) cervical mucus method ( ) withdrawal () Basal body temperature ( ) others (specify)____________ B. Artificial contraceptives ( ) condoms ( ) IUD ( ) pills ( ) others, please specify ___________ C. Permanent ( ) vasectomy ( ) tubal ligation 10. Infant Feeding Program ( )Breast Milk ( ) Commercially Prepared Milk ( ) Mixed Commercially Prepared:: _____Condensed Milk _____Evaporated Milk _____ Powdered Mil Others (please specify) _______________ 11. Maternal Care (Pangangalaga sa mga buntis)

Name (Pangalan)

No. of Pregnancy (Bilang ng Pagbubuntis)

Age of Gestation (Bilang ng Buwan ng Pagbubuntis)

Expected Date of Delivery (Inaasahang Petsa ng Panganganak)

Pre Natal Check Up

Tetanus Toxoid Immunization

12. Immunization Status of Target Age Group (0 12 month)

Name Age in Mos. BCG DPT OPV Hepatitis B 3 1 2 3 AMV Remarks

1 with without with without

incomplete

complete

FIC

Obstetrical history Gravida ____ Para ____ Term____ Preterm ____ Abortion ____ Living ____ Multiple ____ Tetanus Toxoid taken: ( ) TT1 ( ) TT2 ( ) TT3 ( ) TT4 ( )TT5 Prenatal Check-up First trimester: ________________ Second Trimester: _____________ Third Trimester: _______________ Sources of prenatal Check-up ( ) Doctor ( ) Midwife ( ) Nurse ( )hilot ( ) others, please specify: __________________ History of Past illness ( ) vaginal bleeding ( ) PIH/Eclampsia ( ) High Blood ( )Asthma ( ) CVD ( )Diabetes ( ) others, please specify: __________________ Vitamins taken: ( ) Iron with Folic acid ( )Vitamin A ( ) Iodine ( ) others, please specify: _______________________

Garantisadong Pambata: _____________________________

13. Nutritional Status for Children (0 71 months)

Name (Pangalan) Date of Weighing (Petsa ng Pagtimbang) Date of Birth (Kapanganakan) Age ( in months) (Edad) Weight (Bigat) Remarks

14. Leading causes of Morbidity

Name Name (Pangalan) Age Sex Past Illness (past 5 years) Intervention/ Medication
With
Witho ut

Age

Cause of Death

Present Illness

Intervention/ Medication with without

19. Leading causes of Mortality Name

Age

Cause of Death

15. Health Resources A. Health Man Power ( ) Trained Hilots ( ) Healer/ Quack Doctor ( ) Midwife ( ) Nurse ( ) Doctor ( ) others, please specify:__________________ B. Materials ( ) Brgy. Health Station ( ) Health Center ( ) Private Clinic ( )Hospital ( ) others, please specify:__________________ 16. Leading Causes of Neonatal Death (0-28 days) Name Age Cause of Death

20. Leading causes of Maternal Morbidity Name

Age

Cause of Death

21. Leading cause of Maternal mortality Name

Age

Cause of Death

22. Leading causes of Morbidity for Elderly Name

Age

Cause of Death

17. Leading causes of Infant Death Name

Age

Cause of Death

23. Leading causes of Morbidity for Elderly Name

Age

Cause of Death

18. Leading causes of Morbidity