Community Health Nursing

First Semester, SY 2020 -2021

Date: 20 April 2021_______________

Code No. 238purok4,Dantogan________________ (code the household based on the site location)

Demographic Data
Age: _____48____ Religion: _Christian_______
Gender: __________ Male ___ __ Female Ethnic group/ Language at home: Ilokano___
Address/Name of sitio or barangay: __Dontogan _________
Marital status:
_____ Single _____ Living with a partner
_ Married _____ Separated
_____ Widowed

1. How far did you go to school?

_____ I did not attend school _____ College graduate
_ High school diploma _____ Vocational or certification
_____ Some College _____ Trade school
_____ Associate degree Others (Specify): _______________
2. Are you the children’s primary caretaker?
_ Yes _____ No
3. If you have children or other dependents under your care: what is your family situation?
_____ Single mom _____ Raising my children and children of others
_____ Single dad _____ Raising children of family members (grand parent, aunt etc.)
_ _ Two parents _____ No children or dependent
4. How many numbers living in the household?
Number of occupants (currently living in the household): __6__
5. Number of rooms inside the home: __3___
6. Is there any agencies providing the family with help?
_____ Yes (specify): Name of agency ________________________________
_ No
7. What is the employment status?
Full time _____ Seasonal _____
Not working or retired _____ Unemployed _
Part time _____
8. If unemployed, are you currently looking for work?
_____ Yes _ No
9. What kind of job or work do you do for a living?
None
10. If unemployed, specify the reasons below:
My husband and children are the one who are working.

11. What is your housing status?

 _ Owned
_____Rented
_____ Staying with friends or relatives
_____ Sharing with family members
12. What is the family’s income level?
_____ Below 10,000 _____ 20,000 to 25,000 _____ 40, 000 t0 45, 000
_____ 10,000 to 15, 000 _____ 25, 000 to 30, 000 _ 45, 000 to 50, 000
_____ 15, 0000 to 20, 000 _____ 35, 000 to 40, 000 _____ 50, 000 and above
13. Is the income sufficient for the family members?
_ Yes _____ No

14. Does any child or children receive any assistance from the government or any private agencies?
_____ Yes Number of children receiving help (if any): ______
_ No
15. Do you or someone in your home have special needs? _____ Yes, me
_____ Yes, a household member
_____ Yes, a household member and me
_ None
16. If yes, what special needs?
N/A
17. Where does the family usually get their food?
N/A
18. Do you need information on how to prepare or cook food for special diets?
_____ Diabetes _____ Heart disease _ No, I don’t need information _____
Hypertension _____ Glutein free
19. Do you need information on nutrition?
_ Yes _____ No
20. Do you have someone in your household needs any of these health care needs? Check all that apply.
_____ Adult diagnosed with disability _____ Hearing care _____ Pulmonary disease
_____ AIDS/ HIV risk _____ Heart disease _____ STD’s
_____ Child diagnosed with disability _____ Hypertension _____ Substance abuse treatment
_____ Dental care _____ Medical equipment _____ Teen pregnancy
_____ Diabetes _____ Mental health care _____ Transportation to appointments
_____ Eye vision care _____ Prescription medication _____ Sleep problems
_ General Medical care _____ Prosthesis _____ None
21. What diseases are commonly present in your home? Check all that apply.
_____ Hypertension __ Cough and colds _____ Diarrhea
_____ Cardiovascular disease _____ Tuberculosis Others (specify): ______________________
_____ Diabetes _____ Flu or Influenza
_____ Kidney failure _____ Cancer
_____ Urinary tract infections _____ Thyroidism
22. Are you aware of the immunization program?
_ Yes _____ No
 23. How often do you visit the health center or clinic?
_____ None at all _ Sometimes
_____ Seldom _____ Only when needed too
_____ Often _____ Regularly
24. What health programs are you aware that your community neither offers nor provides?
- Vaccination for children agas 0-59 months
- Medical and dental check up
- Maintenance and vitamins for Senior Citizens

26. Are your children fully immunized?

_ Yes _____ No
27. Does the mother aware of the family planning programs in the community?
_ Yes _____ No
28. What family methods do you use? Check all that apply.
_____ Condom
_____ Oral contraceptive pills
_____ Intrauterine device (IUD)
_____ Bilateral tubal ligation (BTL)
_ Natural method
_____ None
29. Is the mother aware on the importance of prenatal checkups?
_ Yes _____ No
30. Does the mother conducted prenatal checkups throughout the course of pregnancy?
_ Yes ______ No
31. What hinders you from using family planning method?
- None.

32. Are there any hindrances in seeking medical help or consultation regularly? Indicate reasons below
(transportation, distance, location etc.).

None.
33. How often does the community health workers do home visits or home care?
_____ None at all _____ Sometimes
_____ Seldom _____ Only when needed too
_____ Often _ Regularly
34. Are there any newborn/infant or child deaths in the family?
_____ Yes _ No
35. Identify the reason or cause of infant or child mortality below.
None.
36. What type of toilet is available in the home?
_____ Open pit _ Flush type _____ No available
37. Are you aware of solid waste management or proper waste disposal?
 _ Yes ______ No
38. Does the household practice waste segregation?
_ Yes ______ No
39. Where do you dispose your solid waste?
_____ Backyard _ Collected _____ Open pit
_____ Into the water ways _____ Compost pit
40. What type of water source does the household use?
_____ Spring water _ Barangay water supply _____ Rain water
_____ River _____ Ground water
41. Is there any presence of local health center in the area or primary health care providers?
_ Yes _____ No
42. Is the area prone for geographical hazards?
_ Yes _ No
43. Lists the geographical hazards in the area based on your observation below (landslides etc.)
- Forest Fire, Flashfloods and Landslide
44. What community organizations do the family involves with? List them below.
None
45.What are the priority problems in the community that needs to be addressed with? Provide
at least three problems below.
- Garbage, Health programs, and sidewalks