PAMANTASAN NG LUNGSOD NG PASIG

College of Nursing
INITIAL DATABASE FOR COMMUNITY ASSESSMENT

Name of Interviewee Date

Address History of residency From___ to ___
Age Province/Area of Origin __________
Sex

A. Family Structure and Characteristics

a. Type of family structure
[ ] Traditional/Nuclear [ ] Extended [ ] Single Parent
[ ] Blended [ ] Cohabited

b. No. of household and the relationship to the Head of the Family

Name Birthday Age Sex Civil Educ. Relationship
Status
Attainment

B. Environment

Housing:
Adequacy of living space
Number of rooms: [ ] 1room [ ] 2 rooms [ ] 3 rooms
Number of person/s per room: _______ (specify)
Housing Structure:
[ ] Concrete [ ] Wood [ ] Dilapidated [ ] Mixed Concrete/Wood
Ownership
[ ] owned [ ] rented [ ] owned by relatives
Ventilation:
[ ] well ventilated [ ] poorly ventilated

Number of windows per household

[]1 []2 []3 [ ] None

Environment Proximal to the house

[ ] Near factories
[ ] Near dumpsite
[ ] Near creek
[ ] Near roads
[ ] Near health center
[ ] Near river

Water Supply:
Source of Drinking Water
 [ ] NAWASA [ ] Deep well [ ] artesian well
[ ] bottled water [ ] boiled

Ways of acquiring water

[ ] through owned lined [ ] shared [ ] bought per container

Water storage
[ ] covered container
[ ] uncovered container

Toilet Facility:
Type of latrine
[ ] water sealed [ ] pit hole
[ ] Flush type
Location
[ ] inside the house
[ ] outside the house
Ownership
[ ] owned
[ ] public toilet
Sanitary Condition
[ ] cleaned everyday
[ ] cleaned once a week [ ] None at all

Status of Electricity:
Meralco Line
[ ] owned [ ] shared

Garbage/Waste Disposal:
[ ] thrown [ ] collected (frequency) ____x a week [ ] Burn
[ ] compost pit

Presence of pollution
[ ] air [ ] water [ ] land [ ] noise

Kind of neighborhood
[ ] slum [ ] congested [ ] village

Type of Community
[ ] urban [ ]rural [ ] rurban

Drainage
[ ] close [ ] open

Communication:
[ ] telephone [ ] mobile phone [ ] internet [ ] none

Transportation:
[ ] car [ ] bike [ ] wagon
[ ] motorcycle [ ] by foot

Infestation of insect and rodents:

Are insect and rodents present:
[ ] Yes [ ] No
What types of rodent and insect are present?
[ ] Mouse [ ] rat [ ] Cockroach [ ] Mosquito [ ] flies
How does it affect your living?
[ ] 100% affects the way of living
 [ ] 50% affects the way of living
[ ] Does not affect at all

Presence of Domestic Animals:

[ ] dogs [ ] cats [ ] birds [ ] carabao [ ] cow [ ] pigs
[ ] ducks [ ] turkey [ ] others

If with dogs, are they vaccinated or not?

[ ] Vaccinated
[ ] Unvaccinated

C. Socio – economic and Cultural Factors:

Total Monthly Income of household:

[ ] below Php 1,000/ month
[ ] Php 3,000 – 5,000/month
[ ] above Php 10,000/month
Religious Affiliation:
[ ] Roman Catholic [ ] Protestant
[ ] Iglesia ni Cristo [ ] Muslim
[ ] Dating Daan [ ] Rizalians
[ ] Php 1,000 – 3,000/month
[ ] Php 5,000 – 10,000/month
[ ] Born Again
[ ] Seventh Day Adventist
[ ] others
Specifiy: ________________

E. Health Assessment of each member (starting October 2011)

Medical History

Interviewer’s guide:
Family History of Disease
[ ] Tuberculosis [ ] Asthma [ ] Hypertension [ ] diabetes
[ ] Hepatitis A [ ] Hepatitis B [ ] Anemia [ ] mental illness
[ ] heart disease [ ] Skin disease [ ] Pneumonia [ ] cleft palate
[ ] fractures [ ] diarrhea [ ] Cancer [ ] others

Chronic Illness:
Name Age Gender Illness Dx’ed by: Vices

Vices:
[ ] with smoking (note number of stick/s per day)
[ ] with alcoholism (note number of bottles per day)
[ ] Use of illegal drugs

Sources of Health Care:

[ ] Health Center [ ] Government Hospital
[ ] Private Hospital [ ] others

For Pregnant women only:

Reproductive System assessment (for mothers and pregnant member)
[ ] Age of menarche _____________________
 [ ] Obstetric history G _T _ P_A_L_)

Name Delivered by Place of Type of Term

delivery delivery

Pre- natal check-up?

[ ] every month
[ ] monthly
[ ] weekly
[ ] none at all

Preferred place of delivery:

[ ] hospital [ ] lying in [ ] clinic [ ] house

Preferred Birth Attendant:

[ ] doctor [ ] midwife [ ] hilot

Choice of Family Planning:

Natural method
[ ] withdrawal [ ] abstinence [ ] calendar method [ ] Lactating Amenorrhea Method
(LAM)

Artificial method
[ ] Condom [ ] Pills [ ] Injectables [ ] Intrauterine Device (IUD)

Caring for Infants 0 -7 months old:

Type of infant feeding (if not breastfeeding, indicate reason/s)
[ ] breastfeeding [ ] bottle feeding [ ] mixed feeding
Reasons for not breastfeeding: __________________________
If bottle fed what type of solution is used?
[ ] Powdered milk [ ] Evaporated milk
[ ] Am
Nutritional Assessment:
Family Member Weight Height

Typical diet per day:

[ ] vegetarian [ ] carnivorous [ ] mixed

Sources of food:
[ ] self-produced [ ] from the market
Budget for food: ____________
Quantity of meal per day
[ ] once a day [ ] 2x a day [ ] 3x a day
[ ] 5x a day

Food storage and cooking facilities:

Where do you cook?
[ ] pugon [ ] electric stove
[ ] LPG gas [ ] charcoal
[ ] firewood
How do you store your food?
[ ] stored in the refrigerator [ ] no seal or cover at all
[ ] sealed or covered

F. Values placed on Disease prevention

Immunization (with children 0-12 mos.)

[ ] Please encircle if the child has the following immunization, Please check (√), if the
immunization is complete.

Name of child Age Immunization Complete Incomplete Remarks

Received

BCG, DPT, OPV,

Hepatitis B, Measles

BCG, DPT, OPV,

Hepatitis B, Measles

BCG, DPT, OPV,

Hepatitis B, Measles

BCG, DPT, OPV,

Hepatitis B, Measles

BCG, DPT, OPV,

Hepatitis B, Measles

Deaths from October 2021 to present:

Name Age Gender Date Cause of Death Relationship

Died