ARELLANO UNIVERSITY

College of Nursing
Jose Abad Santos Campus
3058 Taft Avenue, Pasay City
www.arellano.edu.ph

COMMUNITY HEALTH SURVEY TOOL

Head of the Family (kinikilalang puno ng pamilya): _Carlos Miranda____________________________ Control No. __________
Complete Address (Tirahan): Blk 21 Lot 7 Cadiz St. Cerritos Heights Daang Hari Molino IV, Bacoor City Cavite No. of Family/families (Bilang ng
Pamilya):________
Length of Residency (Tagal ng paninirahan sa lugar) 7 years:______________________________ Surveyed by (Pangalan ng Nag-
survey):______________________
Place of Origin (Lugar na pinagmulan) : Makati City_________________________________ Date (Petsa) :____________________
Ethnic Background (Etnikong grupo na kinabibilangan): Filipino______________________________
Primary Dialect Spoken (Pangunahing Dialektong ginagamit) : Tagalog
Type of Family Structure: (\ ) Nuclear ( ) Extended
Dominant Family Member: __4

COMMUNITY AS A PEOPLE
Family Structure, Characteristics and Dynamics
Education Occupation
No. Name of Relationsh (Edukasyon) (Hanap Buhay)
(Blg) Household ip to the Highest Educational
Member(s) head of Sex Date of Birth Age Civil Religion Educational Status Place of Type Occupational Status
(Pangalan ng the family (Kasa- (mo., day, yr.) (Edad) Status (relihi -yon) Attainment (Antas ng Work (Uri) (Kalagayan ng
myembro ng (kaugnaya rian) (kapangana- (Estado Pinaka-mataas Edukasyon) (Lugar) Trabaho)
pamilya) n sa puno kan) Sibil) na Antas ng
ng Edukasyong
pamilya) natapos
1 Carlos head M 11/27/1977 43 W C C C O Seaman E
Miranda
2 Liza Miranda daughter F 03/15/2001 19 S C CU SS NA U U
3 Tarcelita Grandm F 05/ W C HG NF NA U U
Pascual other-in-
law
4 Erlinda Gadi Auntie F 02/ 75 W C EG NF NA U U

LEGEND: M - Male S – Single C- Catholic EG – Elementary Graduate NF – No Formal Education E – Employed

F - Female M – Married P – Protestant EU – Elementary Undergrad. PS – Presently Studying U – Unemployed
W – Widowed SA – 7th Day Adventist HG – High School Grad SS – Stopped Studying SE- Self employed
CL – Common Law INC – Iglesia ni Cristo HU - High School Undergrad. C – College Grad
 Sep – Separated JW – Jehova’s Witness CU – College undergrad
Others:_____ V - Vocational Place of work: Employed:
I- within the community R- Regular
O-outside the community C- Contracted

COMMUNITY AS A SOCIAL SYSTEM

A. Economic Aspect

19 Community Program ( Ano ang mga alam mo na programa sa komunidad?)

13. Combined Monthly family income (Buwanang kita ng pamilya) Pls. specifiy___________________________________________________
( ) P1,000 and below ( ) P10,001 – P15,000 ( ) P25,001 – P30,000
( ) P1,001 – P5,000 ( ) P15,001 – P20,000 (/ ) P30,001 and above ___/__ aware _____ unaware
( ) P5,001 – P10,000 ( ) P20,001 – P25,000

14. Other sources of income (livelihood) (Mayroon pa bang pnagmumulan ng kita?)

( ) Yes ( /) No 20. Predominant Organizations in the community (Kilalang samahan sa komunidad)
( /) Barangay Council ( ) Sangguniang Kabataan
If yes, what? (kung mayroon, ano ito?) ( ) Couples for Christ ( ) Seniors Citizens Club
( ) sari-sari store ( ) poultry raising ( ) livestock raising ( ) other, pls. specify
( ) craft making ( ) Others {pls. specify}________________
C. Environmental Aspect
15. Monthly family expenditure (Buwanang gastusin ng pamilya)
( ) P1,000 and below ( ) P10,001 – P15,000 (\) P25,001 – P30,000 21. Land Ownership (Pagmamay-ari ng lupang tinitirahan)
( ) P1,001 – P5,000 ( ) P15,001 – P20,000 ( ) P30,001 and above ( ) owned ( ) rented (/ ) lease to own ( ) rent free
( ) P5,001 – P10,000 ( ) P20,001 – P25,000
22. House Ownership (pagmamay-ari ng bahay na tinitirhan)
16. Priority Expenditure, rank it 1 – 7 (1 is the highest; 7 is the lowest) ( ) owned ( ) rented ( /) lease to own ( ) rent free
__1__ food (pagkain) _2___ health (kalusugan)
__4__ house rental (upa sa bahay) __6__ education (edukasyon) 23. Type of Materials Used for house (Uri ng Materyales ng bahay)
__5__ electric bill (bayarin sa kuryente) __7__ clothing (damit) ( ) light ( ) strong (/ ) mixed
__3__ water bill (bayarin sa tubig) ( ) makeshift (barong barong)

17. Resources allotted for Health Care (Nakalaang pondo para sa kalusugan) 24. Ventilation
( /) Yes ( ) No ( ) well ventilated ( /) fair
If yes, from where? (kung oo, galing saan?) ( ) poorly ventilated(requirement: opening 10% of floor area)
( ) Health Insurance ( /) SSS/GSIS
( /) Phil Health ( ) savings 25. Lighting – facilities
( ) others, please specify ________________ ( /) electricity ( ) gasera ( /) kandila
( ) others, pls. specify ___________________
B. Political / Leadership Aspect
( /) adequate ( ) inadequate
18. Recognized leaders in the community
(unang taong kinukunsulta at kinikilalang pinuno ng komunidad) 26. Communication Facilities
( /) Barangay Officials ( ) religious leaders ( ) elders ( ) telepono ( /) internet ( /) TV
( /) Non- government organizations ( ) others, pls. specify ____________ ( /) Radio ( ) Postal system ( ) others____
 D. Health Aspect
27. Transportation facilities ( aroundcommunity)
( ) tricycle ( ) bisikleta 36. Storage of drinking water (Imbakan ng inuming tubig)
( ) Jeep ( /) others shuttle ( ) Jar (banga) ( /) plastic/glass container
( /) bottles ( ) drum
28. Excreta Disposal ( Uri ng Palikuran) ( ) water tank ( ) water dispenser
( ) pail system ( ) open pit privy (/ ) flush type ____/_ covered _____ uncovered
( ) bored hole latrine ( ) closed pit privy ( ) overhung latrine
( ) water – sealed latrine ( ) Antipolo style 37. Method commonly used in sanitizing water
(Paraang ginagamit upang mapanatiling malinis ang inuming tubig)
( ) boiling (pagpapakulo) ( ) filtration (pagsasala
( ) purifier ( ) sedimentation (pagpapalatak)
( ) others, pls. specify __________
29. Ownership of Toilet Facility ( pagmamayari ng Palikuran)
(/ ) private (sariling gamit) 38. Domestic animals upkeep (dogs and cats only)
( ) shared (may kahati sa gamit)
( ) public (gamit pambayan) Kind (Uri) Number Place kept Vaccination (Bakuna sa hayop)
(bilang) (pinaglalagyan) With (mayroon) Without (wala)
30. Sewerage/Drainage System in the community ( Uri ng kanal sa komunidad)
( ) blind drainage (/ ) open drainage ( ) none

31. Condition ( kalagayan ng daloy ng tubig sa kanal)

(/ ) free flowing ( ) stagnant ( If vaccine was given more than a year ago, it must fall under without vaccine)

32. Container used for garbage 39. Present of vectors and rodents (pagkakaroon ng peste sa bahay)
( /) garbage bag ( ) waste basket ( ) sack ( ) none ( ) flies (langaw) ( ) termites (anay) ( ) rats (daga)
(/) covered ____ uncovered ( ) roaches (ipis) ( ) mosquitoes ( lamok) ( ) others _____

33. Do you segregate? 40. Presence of breeding sites of vectors ( pagkakaroon ng lugar na pinamamahayan ng mga peste)
( ) Yes (/ ) No ____ with ____ without
34. Type of waste disposal used (Uri ng pagtatapon ng basura)
( ) animal feed ( ) composting 41. Ways of controlling vectors (Paraang ginagawa upang mapuksa ang mga
( ) open dumping ( ) burial pit ( ) fumigation (pag-papa-usok) ( ) insecticides ( pmatay insekto)
( ) burning ( / ) garbage collection (DPS) ( ) fly traps ( ) mouse traps
( ) others, pls. specify ____________ ( ) screen on doors and windows ( ) others ________
If Garbage is collected, how often? ( Kung kinukulekta ang basura, gaano kadalas?
-Every week 42. Community health programs (programang pangkalusugan)
Aware Utilizes
When it is collected? ( Tuwing kelan kinukulekta ang basura? Friday_______________ (Alam) (nagkukunsulta)
( ) Free consultation (libreng konsulta) ______ _______
35. Source of drinking water (pinanggagalingan ng inuming tubig) ( ) Immunization (libreng Bakuna) ______ _______
(/ ) commercially prepared water ( ) deep well ( ) Family Planning (Programa sa pagpapaplano ng pamilya) ______ _______
( ) local water system ( ) rain water ( ) Pre-natal Check up (programa para sa buntis) ______ _______
( ) artesian well ( ) streams, rivers or spring ( ) Well-baby clinic (konsulta para sa mga sanggol at bata) ______ _______
( ) others, pls. specify __________ ( ) DOTS ______ _______
( ) Others (Pls. Specify) ____________________________ ______ _______
If not utilized, why?__________________________________ 44. Method of Family Planning (Pagpaplano ng pamilya)
( kung hindi napapakinabangan, bakit?)
L- lokasyon ng Health center Name Age Acceptor Non- Acceptor Utilizes
H- hindi maganda ang pagtrato ng health worker
A- hindi sapat ang distribusyon ng serbisyo
K- kakulangan ng kagamitan sa health center
-Kawalang tiwala sa nangangasiwa
O- others

If not utilized, why?______________________________

43. Family Health Practices

(kung hindi pinakikinabangan, bakit?
Health Practices Practices Not Practiced Frequency L- lokasyon ng health center
Smoking / H- hindi maganda ang pagtrato ng health worker
A- hindi sapat ang distribusyon ng serbisyo
Drinking Alcohol / K- kakulangan sa kagamitan sa health center
Others / O- others__________
A. Natural
44. Food usually eated ( madalas na kinakain) ( ) rhythm
( ) Fish ( /) Meat ( ) Vegetable ( ) Mixed ( ) cervical mucus method
( ) withdrawal
45. Food storage practices. (Pangangalaga sa pagkain) ( ) basal body temperature
( /) refrigerator ( ) table ( ) basket ( ) others ( ) others __________

46. First person consulted in times of illness (Unang taong kinukunsulta tuwing nagkakasakit) B. Artificial contraceptives
( / ) doctor ( ) albularyo ( ) midwife ( ) relatives ( ) condoms ( ) IUD ( ) pills ( ) others __________
( ) nurse ( ) faith healer (/ ) family
( ) BHW ( / ) hilot ( ) others (pls. specify)______________ C. Permanent
( ) vasectomy ( ) tubal ligation
47. Medications taken during illness (Gamot na iniinom)
(/ ) prescribed ( ) herbal ( ) over the counter

48. Disaster Management Assessment  For items 45 – 48: Answer only if applicable
Yes No o 46 and 47 – If there are children 0 – 12 months in the family
Awareness of fire station Tel. # ____/__ ______ o 48 – if there are children 0 – 83 months (0 – 7 yrs) in the family
Awareness of police station Tel. # ____/__ ______ o 46 – if there is a pregnant member of the family
Level of preparedness in case of fire ______ __/____
or security arises ( drills) 45. Infant Feeding Program
presence of hazards in the community:
natural ( earthquake, typhoon, etc) ______ __/____ ( ) Breast Milk ( ) Commercially Prepared Milk ( ) Mixed
human made (pollution, fire, toxic waste) ______ __ /______
socio- natural ( drought , flooding) ______ __/___ Commercially Prepared::
_____ Condensed Milk _____ Evaporated Milk

_____ Powdered Milk _____ Others (please specify) ________________