FAMILY SURVERY FORM

No. of Families : ________________________________ Student’ Name : ________________________________

House Number : ________________________________ Course /section : ________________________________
Respondent’s Name : ________________________________ Date : ________________________________
Address : ________________________________

Age : ________________________________

I. General Information
A. Family
Members of the Family Age Sex Civil Religion Highest Source of Social Residence: Length of Dialect Monthly Height Weight
Status Educational Income/ Security Transient/ Residency Used Income (cm) (kg)
Attainment Occupation Membership Permanent
(e.g. SSS,
PhilHealth,
4Ps)

1.

2.

3.

4.

5.

6.

7.

8.
9.
10.

B. Present health condition in the Family (Including AP, PP, etc.) for the past two weeks

Member of the Onset of Illness Medical Attendance Confinement Problems Diagnosis Action Taken
Family With Without Probable Diagnosis
Symptoms if Undiagnosed

C. Death in the family during the last past 5 years (including abortion and still birth)

Name Probable Year Probable Cause Medical Attendance

With Without
 7. General Cleanliness of the house
() Satisfactory
() Unsatisfactory
II. Housing Condition and Environment Sanitation 8. General Cleanliness of the Surroundings
A. House () Satisfactory
1. House () Unsatisfactory
() Owned 9. Kitchen
() Rented () Electric stove
() Shared () Fire wood
() Gas stove
2. House Type
() Charcoal
() Strong () Others/specify: _______________
() Mix 10. Size
() Light () Length in meters
3. Materials Used () Width in meters
() Nipa
() Bricks B. Source of Water
() Wood 1. During Dry Season
() Bamboo () Pump
() Lawanit () Spring
() Galvanized iron () Nawasa
4. Presence of Accident Hazards () Others/specify: _______________
() Broken stairs 2. During Wet Season
() Pointed sharp objects () Pump
() Fall Hazards () Spring
() Poisons/Improperly stored medicine () Nawasa
() Fire hazards () Others/specify: _______________
() Obstructed entry/exit 3. Distance between water source from the House/Toilet
() Cluttered living space () in Meters: _______________
5. Lighting Facilities 4. Storage of Drinking Water
() Electric () Jar with Faucet
() Kerosene () Bottles
() Others/specify: _______________ () Drums
() Plastic
6. Ventilation () Others/specify: _______________
() Well ventilated (with windows) 5. Frequency of Cleaning the Containers
() Poorly ventilated () Everyday
() 3 times a week
 () 2 times a week () Others/specify: _______________

2. Methods Used in Treating Drinking Water () Open stagnant canal

() Chlorination () Closed blind
() Boiling () Open unlined
() Others/specify: _______________ () Others/specify: _______________

C. Waste Disposal
1. Toilet Facilities F. Vermin and Insects
() Owned 1. Types
() Shared () flies
2. Types of Toilet () rats
() mosquitoes
() Pit privy (closed/open)
() cockroach
() Pail system () others/ specify__________________
() Antiseptic 2. Methods Used in Eliminating
() Water sealed () fogging
() Others/specify: _______________ () killing
() screening
3. Distance of the Toilet from the House in meters () trapping
________________________________ () poisoning
4. General Cleanliness () request for help
() Satisfactory () none
() Unsatisfactory () others/specify_______________
G. Pet Animal
() dog
D. Garbage Disposal
() cat
1. Method of Disposing
() thers/specify______________
() Hog feeding
() In a pit
H. Background Gardening
() In the river
() Fruit bearing
() Open dumping
() herbal
() Open burning
() vegetables
() Others/specify: _______________
() others/ specify____________

E. Drainage System III. Nutrition

1. Type 1. Approximate weekly budget for food______________
2. Food usually bought, prepared and eaten
______________________________________________ 6. Storage of food
3. General Impression of Nutrition Status () refrigerator
() basket
1. List of food items that the pregnant women usually eats () table with cover
() fish () others/specify
() eggs __________________________
() vegetables
() meats IV. Pre-natal and Post –Natal Care
() fruits 1. Presently pregnant___________________
() others/ specify__________________ Last menstrual period ________________
2. List of food items given to the baby after birth aside Age of pregnancy___________________
from breast milk Expected date of delivery_____________
() boiled water with sugar 2. Did she have pre-natal supervision?, If yes, to whom and
() ampalaya juice where?
() honey () yes __________________________
() others/ specify () no
3. List of foods given to children aside from breast milk 3. Anyone who have just delivered?
() am () yes
() porridge () none
() Milk formula 4. Gender of the baby
() eggs () male
() potatoes () female
() others/ specify___________ 5. Where was the baby delivered?
4. At what age are these foods given? () at home
__________________________ () at the lying in
5. List of foods usually given to children for snacks () at the hospital
() bread () others/ specify___________________
() boiled banana 6. Who attended the delivery?
() fruits () doctor
() juice () midwife
() others/specify () others/ specify
__________________________ _________________________
a. Infant Fairly Well
nourished nourished
b. Pre-schoolers
c. schoolers
d. adults
7. Did the baby have a well-baby check up?, if yes to 3. Heard about family planning? If yes to whom?
whom and where?______________________________ () yes _____________________________________
() yes () no
() none 4. Method presently using? How long?
8. Vaccination the baby has; _____________________________________
() BCG
() Hepa B VI. GENERAL HEALTH BELIEFS AND PRACTICES
() Pentavalent 1. Understanding of the common cause of illness of the
() OPV people in the community.
() IPV () poor personal hygiene
() MMR () evil spirit
() others specify () night air
_________________________ () inadequate rest
9. Other children () inadequate food
1. Type of immunization received () poor environmental sanitation
_____________________________ () contact with person with communicable diseases
2. Reason for not being immunized () other/ specify _________________________
_____________________________ 2. When is hospital or health center used?
() only if there is sick member of the family
V. Family Planning () when there is a pregnant who is about to deliver
1. Desired number of children () when a child is needed to be immunized
() 2 () other/specify
() 3 ______________________________________
() 4 3. First person to be consulted in times of illness
() others/specify_________________________ () rural health doctor
2. Methods preferred for fertility regulation () spiritista
() withdrawal () herbolaryo
() IUD () private doctor
() pills () nurse
() rhythm () midwife
() jellies () other/ specify __________________
() abstinence 4. Was there a family member who needed medical help but
() condoms did not seek consultation?
() implant () yes
() ligation () no
() vasectomy 5. If yes, what was the reason?
() others/ specify__________________ () could not afford
 () no ride available () other/specify
() against religious beliefs 13. Number of hours of nap per day
() patient refused () 2 hours
() no idea where to bring the sick () 1 hour
() other/specify () 30 mins.
6. Did you consult a dentist? If yes, when? () other/ specify
() yes, ___________________________ ___________________________
() no 14. How many glasses of water taken everyday?
7. If no, are there any reasons for not consulting? () 8 glasses
() financial restraints () 10 glasses
() afraid of the dentist () 6 glasses
() others/ specify () other/ specify
________________________________ 15. Other fluids intake
8. Is there anyone in need of dental service right now? () coffee
() yes () tea
() no () juice
() other/ specify
9. What is being used to clean the teeth?
() tooth brush with toothpaste
() tooth brush with salt VII. RECREATION
() guava twig 1. Recreation activities present in the community
() other/ Specify ______________________ () play ground
() cockpit
10. When is washing of hand necessary? () gambling
() before and after eating () games
() after using toilet Outdoor________
() after touching dirty things Indoor__________
() other/ specify _____________________________ () others/ specify ________________________
11. Use for handwashing 2. What are the leisure activities of the family when resting?
() plain water () drinking spree
() water and soap () play cards
() hand sanitizer () watching TV
() other/ specify ___________________________ () listening to radio
12. Number of hours of sleep every night () Face book
() 4 hours () other/ specify __________________________
() 8 hour
() 2 hours
 3. Is there any member of the family who smoke? If yes, () other/ specify____________________
number of packs/sticks per
day.______________________________ 3. Common problems on waste disposal
4. Type () not collected on time
() tobacco () dispose anywhere
() vape () no dump site
() cigar 4.Common diseases in the community
() other/ specify () cough and colds
_______________________________ () Dengue Fever
5. Is there any member of the family drink alcoholic () Tuberculosis
beverages? If yes, what type () diarrhea
_____________________________________________ () other/specify _____________________
() yes 5. How often do you go to Barangay Health Center/ RHU?
() no _______________________________________________

VIII. EXPENDITURES 6. How many are unemployed in the family

1. What are the common expenses of the family? ________________________________________________
() housing / rental
() food
() utilities (Meralco, Nawasa , etc)
() education
() clothing
() transport
() illnesses/ sickness
() other/ specify _________________________

IX. COMMON PROBLEM IN THE COMMUNITY

1. If somebody is ill, who is the first person to be approached?
() Brgy. Captain
() Brgy. Council
() midwife
() nurse
() family
2.Who makes the decision for any project/activities in the brgy.?
() Brgy. Captain
() Brgy. Council
() people
 X. FILIPINO FAMILY APGAR prescribed or out the prescribed
doing it unsafely procedure safely and
efficiently, with the
Palag Paminsan- Halos understanding of the
i minsan Hindi principles involved
(2) (1) (0) and with confident
A Ako’y nasisiyahan dahil nakakaasa ako and willing attitude.
Knowledge of Totally Has some general Knows the salient
ng tulong sa aking pamilya sa oras ng Health condition uninformed or knowledge of the facts about the
problema. misinformed about disease or disease well enough
P Ako’y nasisiyahan sa paraang the condition condition, but has to take necessary
not grasped the action at the proper
nakikipagtalakayan sa akin ang aking underlying time, understands the
pamilya tungkol sa aking problema. principles, or is rationale of care, able
partially informed. to report significant
G Ako’y nasisiyahan at ang aking pamilya symptoms.
ay tinatanggap at sinusuportahan ang Application of Family diet Failing to apply Household runs
aking mga nais na gawin patungo sa principles of grossly inadequate some general smoothly, family
person and or unbalanced, principles of meals well selected;
mga bagong landas para sa aking general hygiene necessary hygiene. habits of sleep and
ikauunlad. immunization not rest adequate to rest.
A Ako’y nasisiyahan sa paraang secured for
children; house
ipinadadama ng aking pamilya ang dirty, food handled
kanilang pagmamahal at nauunawaan in unsanitary way;
working beyond
ang aking damdamin katulad ng galit, reasonable limit;
lungkot, at pag-ibig. children and adults
R Ako’y nasisiyahan na ang aking getting too little
sleep.
pamilya at ako ay nagkakaroon ng Health Attitude Family resents all Accept health care Understands and
panahon sa isa’t-isa. health care; has no in some degree, but recognizes need for
confidence in with reservations. medical care in illness
doctors, uses and for the usual
patent medicines preventive services,
and quack accepts illness calmly
nostrums; practice and recognizes the
folk medicines or limits it imposes
superstitious rites while doing all
in illness. possible to effect
recovery and
rehabilitation.
Emotional Family does not Family members All members of the
Competence face realities- usually do fairly family able to
assumes moribund well, but one or maintain a reasonable
IX. Family Coping Index patient will get more members degree of emotional
Area 1 3 5 well; one or more evidence lack of calm, face up to
Physical Family failing Family providing All family members, member lacking in security or maturity. illness realistically
Independence entirely to provide partially for needs whether or not there any emotional and hopefully.
required care to of its members, or is disability in one or control-
one or more of its providing care for more of its members, uncontrollable
member. some members but are receiving the rages; one or more
not for others. necessary care to members
maintain cleanliness, alcoholic,
including skin care. suspicious of one
Therapeutic Family either not Family carrying Family able to another, evidences
Independence carrying out some but not all of demonstrate that the of great insecurity.
procedure the treatments. members can carry Family Living. Family consists of Family gets along Family does things
 a group of but has habits or together, each
individuals customs that member acts for the
indifferent or interfered with the good of the family as
hostile to one unity of the family. a whole; children
another, or respects parents and
strongly vice-versa; family
dominated and tasks shared.
controlled by a
single family
member.
Physical House in poor House needs some House in good repair;
Environment condition- unsafe, repair or painting provides for privacy
unscreened; but fundamentally and is free of
neighborhood sound; accidents and pest
deteriorated- neighborhood poor hazards; free from
juvenile and adult but possible to undesirable social
delinquency no protect children elements.
recreational space from poor social
except streets. influence through
education and other
community
activities.
Use of Family has Family is aware of Family uses the
Community obvious and and uses some, but facilities they need
Facilities serious social not all of the appropriately and
needs, but not available promptly. Feels
sought or found community secure in their
any help. resources that they relationship with
need. community workers
such as social
workers, teachers,
doctors, etc.