COMMUNITY HEALTH NURSING SURVEY FORM

Name:
Age:
Date of Birth:
Address:
Mother's Name:
Father's Name:
Contact no.:

Erwin Jhon Ropa

1 y/o
March 10,2013
67 Orange rd. Potrero, Malabon
Joyce Dizon
Ednil Ropa
0912-383-8327

I.Family Structure and Characteristics

-Type of Family Structure
*Nuclear Family
-No. of the household
*3 members
II.Socio-economic and Cultural
Characteristics
-Occupation
*Father: none
*Mother: none
-Monthly Income
*none
III.Home and Environment
-Type of Home
*Mixed
-Presence of Vector of Diseases
*Cockroaches, Flies, Mosquito, Rats
-Food Storage
*They only buy foods on the store for their own.
-Cooking Facilities
*Gas Stobe
-Water Supplies
*They only get water supplies to their
community.
-Toilet Facilities
*Water sealed
-Garbage Disposal
*DPS
-Social Facilities Available
*Church & Clinic

IV.Health Status of Each Member

-Past History of the Family
*There is no history of diseases from their
family.
-Hospitalization
none
-Anthometric Measurement
*BMI= W(11kg)/H(52cm)=40.68 BMI
-Diet History
*Eating vegetables, fruits and meats
-Diagnostic Procedure Done
*none
V.Values and Habits
-Exercises
*none
-Relaxation Technique
*Sleeping
-Immunization Procedure
*Complete Vaccine

Submitted by:
Mary Joy C. Luna
BSN2-1