FAMILY SURVEY FORM

Barangay ____, Legazpi City Purok_____ Household Number________

I – FAMILY STRUCTURE AND CHARACTERISTRICS

A. Family Members

Name Relationship Age Sex Birthday Civil Highest Occupation Monthly

Status Edu- income
cational
Attainment

B. Type of Family Structure ( )nuclear ( ) extended ( )Others

C. Dominant family Member in terms of decision making______________________________

II. SOCIO-ECONOMIC AND CULTURAL FACTORS

A. Monthly Income:________________________
B. Religious Affiliation:______________________
C. What are the traditional beliefs observed in the family?
( ) amulets or anting-anting ( ) supernatural being ( ) albularyo ( ) pamahiin ( ) others___________

III. HOME AND ENVIRONMENT

A. Home
1. House ( )owned ( ) rented ( ) rent-free
2. Lot ( )owned ( ) rented ( ) rent-free
3. Construction Materials Used ( ) light ( ) strong ( ) mixed
4. Number of rooms for sleeping:_____
5. Lighting facilities: ( ) electricity ( )kerosene ( ) candles
6. Ventilation ( )adequate ( )inadequate
7. Furniture Available ( ) living room set ( )cabinets ( ) dividers Others_____________
8. Appliances Available ( ) TV ( )radio ( ) electric fan ( ) others
9. Presence of Rodents & Insects : ( ) no ( )yes What are those?______________________
10. Presence of Accidental Hazards : ( ) ( ) yes What are those?_______________________

B. Kitchen
1. Food Storage ( ) refrigerated ( )non-refrigerated ( )covered ( )uncovered
2. Cooking Facilities ( )LPG ( ) Charcoal ( ) Firewoods

C. Drinking Water Supply

1. Water Supply ( ) private ( ) Public
2. Type ( ) open dug wells ( )artesian well ( ) spring
( ) waterwork system ( )water refilling station
3. Storage ( ) direct from faucet ( )large covered container ( )large uncovered Container others_____

D. Waste Disposal
1. Method of garbage disposal ( ) collected ( ) waste segregation ( ) open dumping
( ) burning others_______
2. Drainage system ( ) open ( ) close ( )none
 3. Toilet Type ( ) water sealed ( ) septic tank ( ) antipolo ( ) none
( ) ballot system ( ) Pail system ( ) public toilet ( ) over hung latrine
( ) bored-hole latrine Distance from the house (in meters) ______________________

E. Domestic Animals
Kind
___________________
___________________
___________________
F. Plants/Trees: Fruit Bearing:_______________________________________________________________
Herbal Plants
______________________
______________________
______________________
Number Where Kept
_______ __________________________
_______ __________________________
_______ __________________________
Ailments Method of Preparation
_____________________ _________________________
_____________________ _________________________
_____________________ _________________________

IV . HEALTH ASSESSMENT

A. Immunization Status (0-12 mos.)

B. COVID 19 Vaccination Status

C. Nutritional Assessment (0-6 years)

Name DOB Age in months Weight Degree of
Malnutrition

D. Infant Feeding Practices (0-12 mos)

( ) bottlefeeding ( ) breastfeeding ( ) mixed
E. Lifestyle Practices
( ) smoking ( ) drug addiction ( ) drinking alcoholic beverages ( ) faulty diet
( )sedentary lifestyle
F. Family Planning method Used : _______________________________________
G. Obstetrical History (HBMR)
H. Health History
1. Past Illnesses (12 mos)_____________________________________________________________
2. Present Illness___________________________________________________________________
3. Death (Past 12 mos)__________________________cause of Death_________________________
4. History of Hospitalization______________________cause________________________________
5. Medical Check-up : ( ) No ( ) yes, how often _______where_____
I. Health Problems Identified in the Community______________________________________________

V. HEALTH RESOURCES: What Barangay Health Services in the community are availed by the family?

( ) Immunizations ( ) Feeding Programs ( ) seminars

( )Medical Check-up ( ) Free Medicines ( ) others___________________________

INTERVIEWER_____________________________

DATE____________________________________