FAMILY AND COMMUNITY SURVEY FORM GUIDE

nd
(Utilized in Level II for Application of Health Care Process to the Family Client- Updated 2 Sem 2004)

FAMILY NAME: _________________________

INFORMANT: __________________________
HEALTH CENTER: _______________________

ADDRESS OF FAMILY: ___________________________________________________________________________________

(House #, Purok or Zone, St. #, Barangay, Municipality, Province)
SURVEYED BY: _________________________
DATE SURVEYED: ______________________

I. ALL MEMBERS LIVING IN HOUSEHOLD (DURING THE CONDUCT OF SURVEY)

Name of Family Members

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.

Relationship to
Head of Family

Position

Age

Date of
Birth

Gender

Marital
Status

Religion

Ethnic
Group

Educl
Attainment

Occupation

Place of
Residence

Dominant DM
Health

Money
others