COMMUNITY HEALTH ASSESSMENT TOOL

1. Background Information

Date:

Family Name:
Family Structure:
Family Stage:
Year of Residency:

Usual Source of Medical Care:

Place of Origin:
Nationality of Foreign:
Religion:

Profile
Name

Relationship to
the family head

Sex

Age

Occupation

Educational
Attainment/
Background

Religion

Civil
Status

Monthly
Earning

Note: indicate if pregnant women AOG, EDC, GP, TT received.

For children 0- 5 years old
Name

Age

Sex

Weight

Height

Type of Feeding
( BF, Bottled
Fed, Mixed,
Supplementary)

Immunization
(Fully
Immunized,
Incomplete,
Defaulter (0-1
year)

Educational
Level

B. Health condition for the past year (only if with deviation from normal)
Name of Sick
Member

Ailment

Occurrence

Treatment
a. Procedures
b. Medications

Present
Consultation

C. Deceased Family Number

Name of Deceased

Cause of Death

Date Died

II. Environmental Status

A. HOUSING
1. Type
___Strong (concrete)
___Light (wood)
___Mixed (concrete, wood)
___Others (specify)
2. Ventilation
___Well
___Poor
3. Lightning
surroundings (to be
___Well
___Poor
Source:

4.

Rooms
__1
__2
__3 or more

5.
Ownership
__rented
__owned
Others (specify)
6. Overall impression of the house and
answered by the surveyor)

___Electricity
___Kerosene
___Others (specify)

B. WATER
1. Source of water supply
__NAWASA
__deep well

__water refilling station

(if NAWASA choose whether)

a. Owned
b. communal
2. Storage
__Container
__covered
3. Distance from House:
C. Excretal Disposal
1. Toilet Facility
YES ( )
__Water Sealed
__Open pit
__Hanging bullet
__Flush
__Others (specify)
D. Garbage Disposal
1. Method of Disposal
__Open pit

__uncovered

NO ( )
__ballot system (wrap &threw)
__sewerage system
__others (specify)

__garbage collector

E. Food Establishment (if any within community)

Permit:
YES ( )
NO ( )
1. Establishment
__Sari- sari store
__carinderia

__burning

__Ambulant vendor
__Others (specify)
2. Storage: How?
F. DRAINAGE SYSTEM
__others (specify)
__Good
__Poor (specify)

__talipapa

__open

__blind/closed

G. ANIMAL RAISED
1. Type/ Kind
___Domestic (specify)___
___Stay (specify)___
H. APPLIANCES OWNED
Vehicles: type
Refrigerator
TV
VCR
Stereo/ radio
Computer
LD/CD

electric fan
oven/ stove
washing machine
video camera
sofa
others (specify)

I. COMMUNICATION FACILITIES
Cellphone
Telephone
Radio
J.

ACCESSIBILTY TO COMMUNICATION FACILITY (hospital, market, school,

church, etc.)

III. NUTRITIONAL STATUS

A. FOOD PREFERENCES (general)
__Vegetables
__Poultry (chicken)
__Beverages
__Water

__pork
__fish

__beef

__soft drinks

__juices