RAWAL COLLAGE OF NURSING

COMMUNITY HEALTH ASSESSMENT QUESTIONAIR

1. Territory

a. Name of the area

b. Type of area Urban Rural

2.
Biographic data

a. Name of the head

of the family
b. Type of family Single Joint
Number of children Alive Dead

c. Religion Muslim Christian other

d. Name Relation with Age Gender Education Occupa Income Vaccination

head of family tion
a)

b) 2
c) 3
d) 4
e) 5
f) 6
g) 7
3. Housing Condition

a. Type of house Pucca Semi pucca Kucha

b. Occupancy Tenent Owner

c. Ventilation Adequate inadequate No ventilation

d. Sunlight Adequate sunlight Some sunlight No sunlight

e. Is there any lawn Lawn Small garden No greenery

/green area

4. Hygiene

Daily bathing Yes No sometimes Hand washing (after toilet Yes No sometimes
&before meals)
Dental care Yes No Head care (lices) Yes No

5. Water sources

a Drinking water Tap/hand pump Filter plant/instant filter Boiled water

/govt supply
6. Kitchen Separate Corner of room Veranda

7. Sewerage/Drainage

a. Indore Open Partially covered Underground

b. Outdoor Open Partially covered Underground

c. Lavatory/Toilet One in house More than one Public toilet Open air defecation

d. Garbage disposal Open Municipal Dumping Incineration other

area containers
e. Streets Pucci Semi pucci Kuchi

d. Air pollution triggers None Industrial Bhattas/fur Paint other

area near by naces industry
8. Community center

Masjid/eidgah School ground Play ground Proper community center building

punchait Union council office Other

9. Available Health Facilities

a. Dispensary yes No b. Rural Health Center yes No

c. Basic Health Unit yes No d. Private clinic yes No

e. Rehabilitation center yes No f. Hospital yes No

10. Distance to nearest health Walking 10-20 minutes More than 30 minutes
facility distance drive drive
11. How do you travel to By walk By local transport By cab / rickshaw
health facility?
12. What service do you prefer in illness?

Medical services/hospital Hakeem Peer/ dum /taweez Homeopathic other

14. Is there any smoker in yes No

family?
15. Is there any LHW/LHV in your area?

16. If yes, frequency of visits?

17. Common health problems in family?

18. Hypertension Heart GI problem

disease(specify) (specify)
Epilepsy Diabetes HIV/AIDS Hep A/B/C polio
(seizures)
Skin disease Asthma/other UTI Tb
(leprosy) resp issue
19. What service do LHV BHU/RHC/Other Dai other
you seek for
pregnant ladies?
20. What feed do you Breast feed Formula milk Cow milk
a. prefer for infants?
b. Feeder care Boil the feeder after Boil sometimes Never boil Only
each feed wash/rinse
21. Do you have any pets? yes No
a.
b. Are the pets vaccinated? yes No

22. Do you participate in leisure activities? yes no specify

23. Does your family prefer cousin marriages? yes No

24. Does any of children in family have congenital abnormality? Yes No

Specify

25. Do you have any knowledge about family planning? yes No

26. Have you adopted any family planning method? Yes No

27. Do you teach your children about safe and unsafe touch? Yes No

28. Is there any other issue you think we should discus about? Yes No

If yes Specify?

29. What kind of media is available?

Telephone Mobile Television/ra Internet Newspaper/ Post/telegraph

phone dio magazines
 Concent form
Iam a student of Post RN BSN in Rawal Collage Of Nursing, We are doing the research on community
Health in Farash town, Islamabad.

The information provided by you will remain confidential. No one except my supervisor and faculty will
have access to it. Your name and identity will not be disclosed any time.

This study is for academic purpose. In this study I will ask few questions regarding health. I require your
cooperation according to your convenience. You are free to participate or withdraw from study any
time. No risk or benefit involved in this research study.

Signature of researcher

…………………………………………………..

Date

………………………………………………….

Participant’s signatures and name

…………………………………………………. …………………………………………………….

Participant’s prints