UNIVERSITY OF SAINT LA SALLE

COLLEGE OF NURSING
BACOLOD CITY

COMMUNITY HEALTH NURSING

Community Health Profile Worksheet
(Worksheet “C”)

Part I: ASSESSMENT OF THE FAMILY

Head of Family__Elmer Torres_________________ Family Number: ________________

Address: _________________Granada________________________Negros Occidental__

House No./Street Barangay Municipality Province

MEMBERS OF THE HOUSEHOLD

RELATION S BIRTHDAY A MARITAL HIGHEST

FAMIlY MEMBER TO HEAD E Month/day/ G STATUS/ EDUC OCCUPATION
X year E RELIGION COMPLETED
No. Name TYPE
OF PLACE
WORK
1 Elmer Torres Head m n/a 36 M RC Elementary Laborer
2 Marissa Torres Wife m n/a 33 M RC Highschool
3 Edison Torres Father m n/a 15 S RC Highschool
4 Alyssa Torres Father m n/a 13 S RC Highschool
5 Eric Torres Father m n/a 8 S RC Elementary

1. Types of Family Structure: Nuclear__✔____ Extended___________

2. Family Size:
 Small (1-4 members)___________
 Medium (5-6 members)____✔____
 Large (7 members and up)_______

Part II. THE EIGHT SUBSYSTEMS:

I. HOME AND PHYSICAL ENVIRONMENT

1. Types of Dwellings:
 Concrete________________
 Wood _________________
 Concrete-wood___________
 Makeshift_______________
 Others: Please specify:________n/a___________

2. Do you have a backyard? Yes___✔___ No_______

3. Residency/length of Stay:
 Month/s__________________
 Years________✔___________
 Others: Please specify_______________________

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4. House ownership:
 Owned__________✔_____________
 Rented_________________________
 Rent-free_______________________
 Others: Please Specify______________________________

5. Land Ownership:
 Owned____________✔_________________
 Rented_______________________________
 Squatter______________________________
 Others: Please Specify________________________________

6. Do you have domestic animals?

No_____________ Yes_____✔_____, What are these?____Dog ___________
_________Chicken________________
_______________________________

7. What kind of weather does your community usually have? ________n/a___________

8. Does your community experience natural calamities?

No_____✔______Yes____________, What are these?___________________
_______________________________
_______________________________

9. Where do you usually go if you experience these?______________n/a_______________

10. Are there reported cases of crimes in your community?

No_____✔______Yes_____________, What are these?___________________

11. Are there reported cases of drug addiction in your community?

No____✔______Yes_____________

12. Do you have electricity?

No_____________Yes_____✔______
13. Means of Cooking:
 Electric Stove________________________________
 Wood____________✔________________________
 Charcoal____________________________________
 Kerosene____________________________________
 LPG________________________________________
 Others: Please Specify:________________________

II. EDUCATION:

1. Are there household members who are presently attending school?

Yes_____✔______No__________

If yes, What level?_________Grade 9, 7 and 2_______________

What is the name of the school?_______n/a____________________________
Where is the school located?________Brgy. Granada__________________
If no, why?______________________________________________________

2. Are there schools in the community?

Yes______✔_________ No______________________
If yes, What are these?_______________________________________________

3. What are the educational facilities of the school in your community?___n/a_____

_________________________________________________________________

4. Is there a school clinic? Yes____n/a_______No__________________

If no, why?_________________

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5. What are the health services offered by the school nurse?______n/a__________
_________________________________________________________________
6. Do people go to school outside the community? Yes____ n/a ____No____________
` If yes, what school?
7. Is there any nutrition program available in your school?Yes__ n/a ____No__________
If yes, what is this? _______________________________________________
8. Are there night school in your community? Yes___ n/a _______No________________
If yes, what school?
Do you avail of this night school program? Yes_____________No ________________
If no, why? ____________________________
_____________________________________
9. Are there schools in the community for special children?Yes____ n/a __No___________
If yes, what school? _____________________
_____________________________________
10. Are there vocational schools in the community? Yes____ n/a _____No_______________
If yes, what school? _____________________
______________________________________
11. Are there PTA’s in the school? Yes_____ n/a ______ No_______________
Are you a member? Yes___________ No___________

III. SAFETY AND TRANSPORTATION

1. Food Storage:
 Refrigerator___________________________________
 Without refrigerator but with cover______✔________
 Others: Please specify___________________________

2. Source of Drinking water:

Deep Well____________ Communal faucets_______________
Rain water____________ Distribution (pipeline)____________
River/stream__________ Others: Please specify___Purified Water___
Artesian Well_________

3. Storage of Drinking Water”

With cover______✔________ without cover_________________
What kind?_____________________________________________

4. Is the water safe for drinking? Yes____ ✔________ No____________

If no, what do you do before drinking the water?_______________________

5. Do you have your own drinking glass? Yes____✔______ No_________________

If no, why?_____________________________________________________

6. Do you have good quality of air in the community? Yes____✔_____ No___________

If no, why?______________________________________________________

7. How do you dispose your garbage?

 Compost pit_____✔______
 Burning________________
 Collected_______________
 Open dumping___________
 Others: _________________

8. Do you practice waste segregation? Yes ______✔_______ No _____________

If no, why?______________________________________________

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9. Do you have a toilet? Yes____✔______ No______________
 Pit privy_____✔_____
 Water sealed________
 Septic Tank_________
 Others: Please specify________________________
 If no, why?_________________________________
10. Are there barangay tanods in the community? Yes___✔_______ No _______________

11. Are there public transportations available in the community? Yes____✔____No_______

If yes, what are these? __Jeepney, Tricycles and Private Motorcycles_______
If no, why?________________________________________________________

12. Is there a fire station in the community? Yes_____n/a______ No____________

How many fire trucks are available?______________________________

13. Are there Police outposts in the community? Yes ___n/a___ No _______________
If no, why?__________________________________________________

14. Who is/are the person/s responsible in resolving conflicts in the community?
Barangay Captain__✔__
Tanod _______________
Police_______________
Relative_____________
Neighbors___________
Others: ______________
15. Is your community generally peaceful? Yes_____✔_____ No______________
If no, why?_______________________________________________

16. Are there household pest? Yes____✔_____ No_____________

If yes, what are these?____flies, mosquitoes, rats and ants _______

17. How do you destroy the pests?_______n/a__________________

IV. POLITICS AND GOVERNMENTS

1. Do you know your purok leader? Yes______n/a__________ No________________

If yes, What is his/her name?______________________________
If no, why? _______________________________________________
2. Do you know your barangay captain? Yes___✔_____No_________________
If yes, What is his/her name?_______”Encargado”__________________
If no, why?_______________________________________________
3. Do you exercise suffrage during election? Yes_____n/a___ No____________
If no, why?_______________________________________________
4. Do you have peaceful elections in your community? Yes___n/a__ No_________
If no, Why?________________________________________________
5. Are you a member of an organization, club, or association in your community?
Yes______n/a______ No _______________
If yes, What organization/club/association?________________________
What is your position? ________________________________________
If no, why? _________________________________________________
6. Where do you run to when you need help?
Barangay Captain____✔______ Priest/Ministers_____________
Purok Leader________________ PTA President______________
Councilman_________________ Landowners________________
Teachers___________________ Club Officers ______________
Others: Please specify;________________________________________

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VI. HEALTH AND SOCIAL SERVICES:

1. Is there presently a sick family member? Yes ____✔_____ No __________________

If yes, Name_____Alyssa__________ Age_____13______ Sex _______F_______
Type of ailment_________Bronchial Asthma__________________________________
Duration of ailment?________n/a________________________________________
Is anybody attending the sick member? Yes ______✔_______ No_______________
If yes, who is attending him/her?
 Doctor____________________
 Nurse_____________________
 Midwife___________________
 Herbolario________✔_______
 Others: Specify_____________
 None_________________ why?
______________________________
2. Immediate dead family member? ________ n/a _________________________________
Cause of death__________________ n/a ______________________________________
3. How often do your family members get sick?
 Once a year_____________________
 Twice a year____________________
 Several times ___________________
 Others_______Occasional__________
4. Common ailments of the family during a year?
 Fever_______✔_________
 Colds________________
 Flu___________________
 Diarrhea______✔________
 Cough________✔_______
 Stomach Ache____✔_____
 Toothache_____________
 Others: Specify_________
5. Where do you usually go when you get sick?
BHS__________________
Private Clinic___________
Hospital_______________
Others: ___Herbolario___
6. Whom do you go to when you get sick?
Doctor _________________
Nurse __________________
Midwife________________
Herbolario______✔_______
Others_________________
7. What medicines do you usually take when you get sick? ________n/a______________
8. Are these medicines prescribed by doctors? Yes ____________ No ________________
If no, why? __________n/a_________________________________________
9. Do you have herbal plants in your backyard? Yes ___________ No ________________
If yes, what are these? ______n/a_____________________________________
If no, why? ______________________________________________________
10. For what ailments do you use them? ___________n/a____________________________
11. Do you use a method in family planning? Yes ___________ No ___________________
If yes, what method?_________n/a___________________________________
If no, why?_______________________________________________________
12. From whom do you learn about the method/s in family planning?
 Neighbour__________n/a_________________
 Friend________________________________
 Relative_______________________________
 Midwife_______________________________
 Nurse_________________________________
 Doctor________________________________
 Priest/Ministers_________________________
 Others: Specify__________________________

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13. Whom do you consult when you are pregnant?
Doctor________✔____________
Nurse_______________________
Midwife_____________________
Trained hilot__________________
Untrained hilot________________
Others: Specify________________
14. Were you given tetanus toxoid immunization? Yes ____✔____ No __________
15. Where do you deliver your baby?
Home_______________________
RHU________________________
Private Clinic______✔_________
Hospital_____________________
Others: Specify________________
16. Do you breastfeed your baby? Yes _________ N o _____________
If yes, for how long?
If no, why?________n/a____________________________
17. Do you give milk formula to your baby? Yes __________ No _______________
If yes, what milk formula? ____________ for how long______________
If no, why ________n/a________________________________________
18. Do you give both milk formula and breastfeeding? Yes ________ No ___________
If yes, why? ________n/a_______________________________________
If no, why? ___________________________________________________
19. At what age do you give supplementary feeding to your baby? ____n/a__________
What kind of supplementary food? __________n/a__________________________

20. How often do you eat the following food?

FOOD DAILY EVERYWEEK 2X A WEEK ONCE A ONCE A
WEEK MONTH
Vegetable ✔
Fruits
meat/poultry ✔
rice/rootcrops ✔
legumes
fish ✔

21. How many of your children are very thin_________, pale___________, with big
abdomen_____✔_______, with skin disease ___________?
22. Do you submit your children for immunization? Yes __✔_______ No ______________
If yes, DPT____________
BCG____________
POLIO__________
HEPA B_________
MEASLES_______
HBS Ag__________
FLU_____________ Others: Specify _______________
23. Do you have Botika in your barangay? Yes _____n/a_____ No___________
If yes, Do you get your medicines from this botika?____________________
If no, why? __________n/a_______________________________________
24. Do you have a hospital in the community? Yes ____n/a___ No___________
If yes, what is the name of the hospital ______n/a_______________
Do you avail of the services in the hospital? Yes__n/a_ No ________
If yes, what are the services? ________________________________
If no, why?__________n/a________________________________
How do you get to the hospital?
 Walk______n/a_______
 Car__________________
 Jeep__________________
 Tricycle_______________
 Tricykad_______________
 Others: Specify__________

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25. Do you have the following health care facilities/services in the community?
Clinical laboratory______________
Ultrasound Laboratory___________
Xray Laboratory________________
Others: Specify_____n/a__________
26. Do you avail of these services? Yes___n/a____ No __________________
27. How do you get to these facilities?
Walk__________n/a____________
Jeepney_______________________
Car___________________________
Tricykad_______________________
Tricycle _______________________
Others: ________________________
28. Do you avail of the services in the BHS? Yes____✔_______ No_______________
If yes, What are these services?
_________Immunization____________________
How often do you avail of the services?
Very often__________________
Often_________✔___________
Seldom____________________
Very Seldom________________
If no, why? ____________________________________________________
29. How do you get to the BHS?
Walk_________✔___________
Jeepney_______✔___________
Car_______________________
Tricykad______✔__________
Tricycle______✔___________
Others:______n/a____________
30. Who is the source of your health information?
Doctor______________
Nurse_______________
Neighbor____________
Herbolario____✔_____
Others:______________

VI. COMMUNICATION:

1. Do you read newspapers? Yes _____________ No_______✔____

If yes, what newspaper?___________________________________
How often do you read?___________________________________
If no, why?______________n/a_____________________________
2. Aside from newspapers, do you read other printed materials? Yes _______ No__✔__
If yes, what are these?___________________________________________________
How often do you read?__________________________________________________
If no, why?_________________n/a________________________________________
3. Do you listen to the radio? Yes ____________ No__________✔___________
If yes, AM____________FM_______________
How often do you listen?__________________
If no, why?________n/a___________________
4. Do you watch television? Yes __________ No_____✔_____
If yes, What program? Name of Program/TV Network
News____________ ________________________
Telenovela________ ________________________
Variety Shows_____ ________________________
Game Shows______ ________________________
Cartoons_________ ________________________
Talk Shows _______ ________________________
Others____________ ________________________
How often do you watch?__________________________________________
If no, why?____________n/a________________________________________

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5. Do you have the following entertainment/communication facilities at home?
Television___________________________
Radio_______________________________
Computer with internet_________________
Computer without internet_______________
Telephone____________________________
Cellphone____________________________
Others ___________ n/a _________________

6. How many household members have cell phones? _______n/a__________

7. Where do you usually use the cell phones/telephone?_______n/a________

8. How do you contact in case of emergency?

Telephone_______________
Cellphone______✔__________
Both______________________

9. Do you have post office in the community? Yes______________ No___✔_____

If yes, where is it located?_____________
Do you avail of the postal services? Yes ________ No______n/a_______

10. Do you have purok meetings? Yes___________ No____n/a______

If yes, do you attend the meetings?____________________
How often do you have the purok meetings?_____________
If no, why?_______________________________________

11. Do you have the following communication facilities in the community?

Radio stations_______________
TV stations_________________
Telephone Company__________
Cell Sites________✔__________
Others: ______________________

VII. ECONOMICS:

1. What is the family’s monthly income? ____P4,000-P5,000___

2. What are the family’s monthly expenses?

Budget Food Electricity House Clothes Water Health Education Leisure

Total

3. Do you have income generating projects? Yes___________ No_____ n/a _____

If yes, what? ___________________________
If no, why? ____________ n/a ____________

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VIII. RECREATION:

1. What are the recreational sites that can be found in your community? Outside the
community?_________________ n/a _________________________________________
Do you avail of these facilities? Yes ___________ No_____________
If no, why?______________________________________________________________

2. Do you engage in any sport? Yes __ n/a __ No________

If yes, what sports?_____________________
If no, why?______________________________________________________________

3. Does your community have any sports facilities? Yes___ n/a _____ No___________
If yes, what sports facilities?_______________
If no, why?______________________________________________________________

4. Do you play any card or board games? Yes__ n/a __ No___________

If yes, what game/s?___________________________________________________
If no, why?__________________________________________________________

5. Do you have any tourist spots in your community? Outside the community?
Yes_____ n/a ______No_____________
If yes, what is/are the name/s of the tourist spot/s?____________________________

6. Are there movie houses in the community? Outside the community? Yes_ n/a ___ No___
If yes, do you watch movie?_________________ How often?___________________
What kind of movie do you usually watch?___________________________

7. Are there Churches or religious services available in the community? Yes_✔_ No____
If yes, what are the types of church and religious services?______ n/a ___________
____________________________________________________________________

8. Do you participate in the church or any religious activities? Yes _ n/a _ No________
If no, why?_________________________________________________________

9. Do any churches provide recreational activities or facilities? Yes __ n/a _No_______

If yes, what activities/facilities?___________________

10. Are there social committees, organizations or clubs available in the community?
Yes____ n/a ___ No___________
If yes, what are these organizations/clubs/committees?____________________
Are you a member of any of these?____________________________________

Informant: _____Marissa Torres_____ Surveyed by:___Mary Ann Noble____