Ateneo de Zamboanga University

School of Medicine
MAHAYAG MUNICIPALITY, ZAMBOANGA DEL SUR
SURVEY QUESTIONNAIRE

Respondent: _________________________________ NHTS Number:

Relationship to household head: _____________________ Conditional Cash Transfer (4Ps):  Yes  No
Interviewer: ______________________________ House/Family Number:
Purok: ____________________ Contact No.:
*Qualifier:
- Interviewee must be 18 y/o above and a resident of the barangay

HEALTH INSURANCE
I. FAMILY PROFILE
HEADRELATION TO HH

ATTENDANTPLACE OF BIRTH/
(MM/DD/YR)BIRTHDAY

(Permanent, Self-employed,

FAMILY?LIVING WITH
LEVELEDUCATIONAL

HEALTH CONDITION
WORKING STATUS

ANNUAL INCOME

(Member, Dependent)
CIVIL STATUS

OCCUPATION

PREGNANT?
(cm)WEIGHT
NAME

(kg)HEIGHT
ETHNICITY
RELIGION
(FIRST/MIDDLE/
SEX

BMI

BP
LAST)

Contractual, Part Time)

HH
II. SOCIO-ECONOMIC PROFILE 2. How often do you participate in any of the activities in the barangay?
 Always  Sometimes  Never
A. FAMILY INCOME
1. Household provider: D. POLITICAL FACTORS
 Father 1. Who do you go to when problems arise in the barangay?
 Mother  Mayor  Barangay Councilor
 Children  Barangay Captain  Religious Leader
 Others: __________  Barangay Kagawad  Others: __________

2. Other sources of income: 2. Do you adhere to the policies implemented by the barangay officials?
Annual Income (Php)  Always  Sometimes  Never
Farming
Business (e.g. sari-sari store) 3. Are you satisfied with the services provided in the barangay?
Others (please specify):  Yes
 No

B. CONSUMER BEHAVIOR 4. Which of the following needs improvement?

1. Rank the following based on your priority in expenses:  Health
__ Food __ Personal needs  Education
__ Education __ House maintenance  Transportation
__ Transportation __ Clothes  Communication
__ Bills (water and electricity) __ Health  Sanitation
__ Others: __________  Peace and Order
 Sports and Recreation
2. Does your income sustain your daily expenses?
 Others (please specify): __________
 Yes
 No E. TRANSPORTATION
Why? ____________________ 1. Do you have any owned transportation?
 Yes  No
3. Do you have savings? If yes,
 Yes  No Number Public Private
Bike
C. COMMUNITY INVOLVEMENT
Motorcycle
1. Is anyone in the family a member of a barangay organization?
Tricycle
 Yes
Jeepney
 No
Truck
If yes,
4-wheeled vehicle
Name Organization Position
Kind:
Others:

2. What is your means of transportation?

 Jeepney  Motorcycle (habal)
 4-wheeled vehicle  Bicycle
 Tricycle  Others: __________
3. Have you been involved in a motor vehicle accident? 4. Appliances:
 Yes  No  Television  Refrigerator
 Radio  Electric fan
4. How many times have you been in a motor vehicle accident? _____  Computer/Laptop  Wifi
 Videoke/Karaoke  Air conditioner
5. When were you involved in a motor vehicle accident (month/year)?  Rice cooker  Others: __________
____________________________________________________
5. Ventilation
6. Do you use protective equipment when driving motor vehicles?  Good  Fair  Poor
 Yes  No

F. COMMUNICATION 6. Lighting
1. Source/s of news and/or public affairs:  Candle  Electricity (owned)
 Radio  Cellular phone  Lamp  Electricity (series)
 Television  Poster  Solar  None
 Neighbors  Flyer  Others: __________
 Telephone  Others: __________
C. WATER
2. Mode/s of communication: 1. Source of water
 Cellular phone  Internet a. For drinking:
 Telephone  Poster  Artesian well  River
 Letter writing  Flyer  Deep well  DCWD
 Bulletin board  Others: __________  Water refilling station  Faucet
 Others: __________
b. For secondary contact (e.g. bathing, washing clothes, toileting):
III. HOUSING AND ENVIRONMENTAL CONDITIONS  Artesian well  River
 Deep well  DCWD
A. LOCATION
 Rain  Tubod
1. Where is the house located?
 Tabay  Others: ___________
 Upland
 Lowland 2. Drinking water storage
 Others: __________ a. Container
 Plastic bottle  Pail
B. STRUCTURE
 Clay jars  Pitcher
1. Ownership:
 Glass bottle  Gallon
Owned Rented Free
 Drum  None, directly from faucet
House
 Others: __________
Lot
b. Do you cover your drinking water storage?
 Yes  No
2. Housing materials:
c. How often do you clean your drinking water container/s?
 Light  Concrete
 After every use
 Mixed  Others: __________
 1-3 times a day
3. Number of rooms in the house: __________  1-3 times a week
 1-3 times a month
 Never
 d. Duration of water storage before consumption  Scattered things Good: 0-1
 < 1week  Scattered wastes
 1 week
 > 1 week 6. Water Drainage
 > 1 month  Open  Closed  None

3. Method of water sterilization: E. GARBAGE DISPOSAL

 Boiling  Solar 1. Do you have a garbage container?
 Straining  None  Yes  No
 Chlorination  Others: __________ If yes,
 With cover  Without cover  Tied
D. KITCHEN
1. Where is the kitchen located? 2. Method of disposal:
 Inside the house  Outside the house  Open dumping
 Open burning/ incineration
2. Cooking facility:  Burial pit
 Electricity  Gas stove  Composting
 Charcoal  Coconut husk/wood  Collection by garbage truck
 Others: __________ How often? _____ (days/ months)
 Others: _________
3. How do you store your food to keep it from spoiling?
a. Cooked food 3. How often do you dispose of your garbage?
 Refrigerator  Cabinet  Everyday
 Cover  None  Twice a week
 Others: __________  Once a week
b. Raw food (hilaw)
 Refrigerator  Cabinet 4. Garbage container inside the house:
 Cover  None  Present  None
 Others: __________
c. Leftover food 5. Do you practice segregation?
 Refrigerator  Cabinet  Yes  No
 Cover  None
 Others: __________ F. EXCRETA DISPOSAL
1. Location of the toilet facility:
4. Where do you store your cooking and eating utensils?  Inside the house  Outside the house
 Cabinet
2. Toilet ownership:
 None
 Private  Shared  Public
 Others: __________
3. Type of toilet:
5. Sanitary Condition
 Flush type  Closed pit privy
 Poor  Fair  Good
 Antipolo  Bored hole latrine
Checklist Scoring
 Water sealed latrine  Overhung latrine
 Unpleasant smell Poor: 4
 Open pit privy  Others: _________
 Presence of flies and other pets Fair: 2-3
 Pail system
 If pail system, where is the waste thrown? Breeding sites (/ or X) Presence of mosquitoes (/ or X)
 Trash can Jars
 River Tires
 Anywhere Tab
 Others: _______________ Pond
Stagnant water near home
4. Distance of the toilet from the main water source: Others
 0-50 m
 51-150 m 4. If there are mosquitoes present, what do you do to control the mosquitoes?
 >150 m  Use mosquito nets
 Apply repellant
 Destroy and dispose of breeding sites
5. Toilet sanitary condition  Bury husks
 Poor  Fair  Good  Use screened windows
 Fogging
Checklist  None
Criteria 0 1 2  Others: __________
Surroundings with scattered no scattered no scattered
waste/with trash, waste, no trash, waste, no trash, 5. Animals owned
without trash can without trash can with trash can Animal Number Freed Tied/Caged
Toilet bowl no toilet bowl hole (antipolo, with toilet bowl Chicken
pithole) Pig
Well-structured open area (no four walled, four walled, with Horse
walls) without ceiling, ceiling, with door Cow
with door Carabao
Septic tank without septic clogged drainage with septic Goat
tank/ without tank/unclogged
Cat
drainage drainage
Dog
Water and soap without water and with water, continuous water
Monkey
soap without soap and with soap
Ducks
Rabbit
Scoring
Poor: 0-3 Fair: 4-7 Good: 8-10 Others:

G. ANIMALS
1. What are the common pests seen at home? 6. Is your dog/cat vaccinated?
 Rat  Cockroach  Others: __________  Yes  No
If yes, when was the last vaccination? __________
2. What do you do to control the pests?
 Chemical spray 7. Has your dog/cat bitten someone?
 Mechanical  Yes  No
 Others: __________
8. Has anyone in the family been bitten?
3. Are there mosquito breeding sites seen around the house?  Yes  No
If yes, who? ____________________
 Yes  No
What were the interventions made? ____________________
  Yes (proceed to #2)  No (proceed to #3 and #4)
H. GARDEN 2. If yes, what health services do you avail?
Types of plants in the garden  Wellness consultation
 Vegetables  None  Illness consultation
 Floral plants  Others: ___________  Family planning
 Herbal  Immunization
 Fruit-bearing  Prenatal check-up
 Postnatal check-up
I. HOUSE SAFETY  Dental
1. Presence of health hazards:  Medication
 Broken stairs  None  Others (please specify): __________
 Fall hazards  Others: ___________
 Pointed/ sharp objects 3. If no, where do you go?
 Chemicals  Hospital  Faith healer
 Albularyo  Others: ___________

For chemicals, 4. If no, what are the reasons?

Type Storage  Lack of money
 Lack of supplies
 Lack of human resource
 Lack of services offered
 Distance of the Health Center
 Not aware of the Health Center’s existence
 Embarrassment/fear of the health personnel
 Cultural/religious reasons
IV. HEALTH STATUS
 Others: ______________
A. HEALTH OR COMMUNITY RESOURCES
5. What do you initially do when someone is sick in the household?
1. Exercise
a. Type  Bring to the hospital
 Sports (please specify: __________)  Bring to the Health Center
 Zumba  Bring to the clinic
 Jogging  Bring to the albularyo
 Indoor exercise (please specify__________)  Treat at home
 None  Herbal treatment
b. Duration  Others: __________
 > 30 minutes  < 30 minutes
c. Frequency 6. Do you use herbal plants to cure illnesses?
 7x/ week  Yes  No
If yes,
 5x/ week
Herbal Plant Usage Preparation
 3x/ week
 <3x/ week

B. HEALTH KNOWLEDGE AND BEHAVIOR

1. Do you utilize the Health Center?
  Others: __________

7. How often do you visit the Health Center? b. When do you wash your hands in a day?
 Once a week  Before meals
 Once a month  After meals
 When needed  After using the comfort room
 Sometimes, if remembered  Others (please specify): ___________________

8. Are you willing to go to the Rural Health Unit (RHU) if referred by the midwife/BHW? What do you use?
 Yes  No  Water and soap
If no, why?  Water only
 Lack of money  Others (please specify): _____________  Others: __________
 Distance of the RHU
9. Usual illnesses in the family: c. What do you use to clean your teeth?
___________________________________________________________________  Toothbrush and toothpaste
___________________________________________________________________  Toothbrush only
 Salt
10. What do you do for the conditions stated above?  Husk
 Self-medication  Sand
 Consultation in the  Herbal leaves
 Barangay Health Center  Others: __________
 Hospital  None
 Private clinic
 Municipal Health Office d. How many times do you brush your teeth in a day?
 Once
C. HEALTH PRACTICES  Twice
1. Exercise  Thrice
a. In a week, how many times do you exercise?  More than three times
 Once
 Twice e. Do you go to the dentist?
 Every other day  Yes, regularly
 Everyday  Yes, when needed
 Never  No
b. How many hours do you exercise?
 15-30 minutes What services do you avail?
 1 hour  Regular check-up
 1 hour and 30 minutes  Cleaning
 > 2 hours  Tooth extraction
 Others: __________
2. Personal Hygiene
a. How many times do you take a bath? When your teeth ache, what measure do you do to relieve the pain?
 Once a day  Self-medicate
 More than once a day  Go to the dentist
 Every other day
 When needed 3. Vices
 a. Smoking (Tobacco/cigarette)  Mixed
i. Does anyone smoke at home?  Others (please specify): ____________________
 Yes  No
If yes, d. Viand:
Name Age started Age stopped Number of sticks Serving/s
smoking smoking per day Vegetables
Fish
Meat (specify)
Canned Goods
ii. Where does s/he smoke? _____________ Others (please specify):

b. Alcohol drinking
i. Does anyone drink alcohol? e. Do you use iodized salt in your food?
 Yes  No  Yes  No
If no, why? ____________________

If yes, f. Beverage Intake

Name Age started Age stopped Frequency (e.g. Number of Beverage Amount (cup per day)
drinking drinking once a week) glasses/bottles Water
per drink Fruit Juice
Soft drinks
Coffee
Tea
Others:
What types of alcohol?
 Beer  Tuba 5. Do any of the household members take vitamins or medications?
 Rhum (Tanduay)  Gin (Ginebra)  Yes
 Vino (Kulafu)  Others: ___________ Name Name of Duration Frequency
 Brandy (Emperador) Vitamin/Medication A. everyday
B. as ordered
4. Nutrition C. when needed
a. Do you cook your own food?
 Yes
 No
If not, where is it from? ____________________

b. How many times do you eat in a day? (Full meals)

 Once
 Twice
 Thrice  No, why? ____________________
 More than three times

c. Staple food:
 Corn
 Rice
V. MATERNAL AND CHILD CARE
A. PAST AND PRESENT PREGNANCY
Practices
Place of Birth Type of Birth
Prenatal Checkups during Complicationse Gender
Deliveryb Attendantc Delivery Wt
Age per pregnancyd
Menarche
Name preg-
nancy Yes OB Score Supplements/
Nonea Location TT
(Frequency) (GTPAL) Vitamins

a. If no prenatal, why?
1 Lack of money d. Practices
2 Lack of supplies at the Health Center 1 Use of OTC
3 No health personnel at the Health Center 2 Smoking
4 Lack of services offered 3 Alcohol drinking
5 Time constraints 4 Use of illicit drugs
6 Distance
5 Abortion
7 Others (please specify): __________
6 Others (please specify): __________
b. Place of Delivery
1 Home-delivered e. Complications
2 Barangay Health Center 1 HPN
3 Hospital 2 DM
If home-delivered, why? 3 Heart problem
a) Lack of money 4 UTI
b) Distance from the Health Center 5 Liver Disease
c) More comfortable at home 6 Kidney Disease
d) Others (please specify): __________ 7 STI
8 Facial edema
c. Birth Attendant 9 Blurring vision
1 Trained Birth Attendant 10 Bleeding
2 Health Care Provider (Doctor, Nurse, Midwife) 11 Convulsions
3 Others (please specify): __________ 12 Fever
13 Abdominal pain
14 Dysuria
 15 Others (please specify): __________

f. Presence of maternal death for the past 5 years?

 Yes
 No
If yes, state the cause ____________________

B. CHILD CARE
For children ages 0-5 (If none, skip the table below)

Complementary Usual Meds Last

Supplements/
Breastfeeding Feeding Given When Immunization Dewor- Guardian
Vitamins
Age Birth Birth Place of Birth Sick ming
Name
(Yr/Mo) Order Attendant Delivery Wt Yes Yes No
No
(Exclusive) a
Yes No Full Complete Incomplete Ongoing None

a. Reasons for not breastfeeding  Distance from the health center

 Time constraints  Time constraints
 Inadequate milk production  Not aware of the existence of the health center
 Painful  Embarrassment/fear of the health personnel
 Others (please specify): __________  Cultural/religious belief
 Others (please specify): __________
b. If immunization is incomplete/none, state the reason why?
 Lack of money c. Presence of death of children 0-5 years old for the past 5 years?
 Lack of supplies at the health center  Yes
 No health personnel at the health center  No
 Lack of services offered If yes, state the cause ____________________
 C. FAMILY PLANNING METHODS
1. Are you aware of the existing family methods?
 Yes
 No B. Does anyone in the household have a chronic illness?

Where did you

2. Do you practice family planning? To whom did Treatment
Member Age seek Diagnosis
 Yes you consult? Done
consultation?
 No

If yes:
NATURAL
 Calendar/Rhythm C. Did anyone in the household die within July 2013 up to present?
 Basal Body  Yes
 LAM  No
 Standard Beads Member Age Date Cause of death
 Withdrawal
ARTIFICIAL
 Condom
 Pills
 IUD
 Others (please specify): __________ VII. HEALTH EDUCATION
PERMANENT What topics do you want to be discussed in detail?
 BTL  Drug Abuse
 Vasectomy  Family Planning
 Dengue Prevention
If no, why?  Nutrition
 No idea about family planning methods  Herbal Plants
 Fear of possible side effects  Healthy Lifestyle
 Partner does not allow  Others (please specify): ____________________
 Others: ____________________
VIII. ILLEGAL SUBSTANCE USE
1. Does anyone in the household have a history of substance use?
 Yes  No
VI. HEALTH INDICES
 Prefers not to answer question
A. Did anyone in the household get sick within July 2012 up to present?
 Yes 2. If yes, what illegal substance was involved?
 None  Marijuana
Where did you
Member Age
To whom did
seek Diagnosis
Treatment  Shabu
you consult? Done  Others: ___________
consultation?
3. How long was the history of substance use? ____________

_____________________________________________________
Signature over printed name of respondent