WESLEYAN

AN AUTONOMOUS METHODIST UNIVERSITY

COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES

COMMUNITY HEALTH NURSING SURVEY TOOL

_
Barangay
I. GENERAL INFORMATION

A. Family Data

Head of Family
1. Name of Household Head:
Surname First Name Middle Name
2. Birthday: 6. Age as of last Birthday:
3. Religion: 7. Occupation:
4. Civil Status:
5. Educational Attainment:
Spouse
1. Name of Spouse:
Surname First Name Middle Name
2. Birthday: 6. Age as of last Birthday:
3. Religion: 7. Occupation:
4. Civil Status:
5. Educational Attainment:

B. Type of Family

1. Traditional: 2. Non-traditional:
 Extended  Single parent
 Nuclear  Others; specify:
 Live in partner
c. Family Size
 Large family (6 and above)
 Medium (4-5)
 Small (1-3)

D. Unmarried Members of Family

Name Birthday Age Relationship to Educational Civil Religion Occupation Monthly Income
Household Head Attainment Status

E. For Extended Family

1. Name of Household:
2. Birthday: 4. Educational Attainment:
3. Religion: 5. Occupation:

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 WESLEYAN
AN AUTONOMOUS METHODIST UNIVERSITY

COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES

1. Name of Wife:
2. Birthday: 4. Educational Attainment:
3. Religion: 5. Occupation:
Children/Others

Name Age Birthday Educational Religion Occupation Relation to Monthly Income

Attainment Household Head

II. SOCIO-ECONOMIC PROFILE:

A. Language Spoken (Most Common Language Used by the Family)

 Tagalog  Ilocano  Visaya  Others, specify: _
B. Housing
 Concrete  Wood and concrete  Shanty
 owned  owned  owned
 rented  rented  rented
 free  free  free
 Bamboo/Nipa  All wood  Others; specify:

 owned  owned  owned

 rented  rented  rented
 free  free  free
C. Land Ownership
 Owned  Rented  Others; specify:
D. Power Energy Source:
1. Lighting
 Electricity  Kerosene lamp  LPG lamp
 Others; specify:
2. Cooking:
 LPG  Electric range  Wood
 Charcoal  Others; specify:
E. Appliances Owned
 Cellphone  Refrigerator  Electric Fan  Other; specify:
 TV  Computer  Computer
 Radio  Aircon

F. Transportation Availed
 Tricycle  Truck
 Jeepney  Others; specify:
 Auto/ Van

G. Average monthly Family Income:

III ENVIRONMENTAL HEALTH INFORMATION:

A. Drinking water supply:

1. Source:
 Deep well ( 3 pipes and above)  Shallow well ( below 3 pipes)

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 WESLEYAN
AN AUTONOMOUS METHODIST UNIVERSITY

COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES

 owned  owned
 shared  shared
 Mineral Water
 Open well  Others; specify:
 owned  owned
 shared  shared
 Nawasa
 owned
 shared
B. Garbage Disposal
 Burning  Composting  Segregation  Dumping
 Others; specify:
C. Drainage
 Open  Closed  None
D. Toilet Facilities
1. Sanitary toilet:
 Flush  Buhos
 owned  owned
 shared  shared
2. Unsanitary toilet:
 Antipolo type
 owned
 shared
 Others; specify:
 owned
 shared
3. None/No toilet:

IV. Health information

A. Common diseases encountered from the past 2 years (leading causes morbidity)
1.
2.
3.
4.
5.

B. Common causes of death from the past 2 years (leading causes of mortality)
1.
2.
3.
4.
5.

C. Maternal Nursing
1. Child bearing mothers (15-49 years old)
a. number of pregnancy:
b. number of children born a live:
c. number of infant born dead:
d. number of abortion:
e. last delivery attended by:
f. data on pregnancy:
(Pregnant mothers) LMP:

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 WESLEYAN
AN AUTONOMOUS METHODIST UNIVERSITY

COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES

EDD:
AOG:
Weight:

2. Immunization (Tetanus Toxoid) Provided by: (Health facilities; specify)

TT1 
TT2 
TT3 
TT4 
TT5 

3. Family Planning Methods Used:

A. Natural Method
 BBT  LAM method  Symphothermal method
 Cervical mucous method combination of BBT and CMM

B. Artificial Method
 Pills  Condom  spermicidal
 BTL  Vasectomy  DMPA
 copper-T
C. Others; specify

4. Feeding Practices of Lactating Mothers

 Breast feeding
 Bottle Feeding
 Mix Feeding

D. Infant and Children Nursing

1. Immunization (0-12 months) Provided by: (Health facilities; specify)
BCG 
DPT1 
DPT2 
DPT3 
OPV1 
OPV2 
OPV3 
Hepa. B1 
Hepa. B2 
Hepa. B3 
Measles 

2. Nutritional status (0-72 months)

Name Age Birthday Weight Date of OPT

E. Food
1. Source:
 Market  Store  Vendor  Own produced
2. Selection:
 Fresh  Preserved  Others; specify:

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 WESLEYAN
AN AUTONOMOUS METHODIST UNIVERSITY

COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES

F. Health Resources Commonly availed by the family

1. Hilot/Herbularyo  4. District hospital 

2. Barangay Health Center  5. Private hospital/clinic 
3. Rural Health Unit  6. Others; specify

Surveyed by:

Name of Student: Name of C.I.