Republic of the Philippines

ISABELA STATE UNIVERSITY

COLLEGE OF NURSING
Ilagan Isabela
Community Health Survey Tool

Head of the Family: _____________________________________ Control No.:________________

(kinikilalang puno ng pamilya) No. of Family/Families:_________

Complete Address: _____________________________________ (Bilang ng Pamilya)

(Tirahan) Date:____________________

Length of Residency:____________________________________
(Tagal ng paninirahan sa lugar)

Place of Origin:_________________________________________
(Lugar na Pinagmulan)

Ethnic Background:______________________________________
(etnikonng grupo na Kinabibilangan)

Primary Dialect Spoken:_________________________________

(Pangunahing dialektong ginagamit)
Occupation
No. Name of Household member(s) Relationship Sex Date of Birth Age Civil Highest Educational Educational (Hanap Buhay)
(Blg.) (Pangalan ng miyembro ng pamilya) to the Head of (Kasarian) mm-dd-yyyy (edad) Status Attainment Status Type Occupational
the Family. (Estado (Pianakamataas na antas (uri) Status
(Kaugnayan sa Sibil) ng edukasyon na natapos) (Kalagayan ng
puno ng trabaho)
pamilya)

COMMUNITY AS PEOPLE
Family Structure, Characteristics and Dynamics
Legend:
M- Male S- Single C-Catholic NF- No Formal Education E-Employed
F- Female M-Married P-Protestant EU- Elem. Undergrad U-Unemp.
W-Widowed SA-7th Day Adventist EG-Elem. Graduate
CL-Common Law Wife INC-Iglesia ni Cristo HU-Highschool Undergrad
Sep-Separated JW-Jehova's Witnesses HG-High School Grad
PS-Presently Studying
SS-Stopped Studying
CU-College Undergrad.
C-College Grad
V-Vocational

Type of Family Structure 4. Who would take care the ill/sick member/s?
( ) Matriarchal ( ) Patriarcal ( ) Nuclear ( ) Extended ( ) mother ( ) father ( ) eldest child ( ) others
(specify)______________________________
General Family Relationship (describe briefly):
A. Husband- wife relationship_______________________________ 5. Remedies to common illness
B. Parent- Sibling relationship_______________________________ ( ) over the counter drugs ( ) prescription medicines ( ) herbal
medicines ( ) others (specify):
Dominant Family Members in terms of decision making ______________________________
( ) mother ( ) father ( ) eldest child ( )
others( specify)__________________________ 6. Personal Habits/ practices affecting health:
A. Drinking of Alcohol______________ frequency_________
II. Family Health Assessment B. Smoking________________ frequency_________
C. Walking Barefoot______________________
1. History of illness/disease: __________________________ D. ( ) others (specify)______________________________

2. Presence of Illness state (current Health status): 7. Sleep Pattern/ practices:

______________________________________________ A. Usual Sleep time:___________________________
B. Usual wake up time:_________________________
3. In times of sickness, where do the family seek treatment C . Nap ( ) yes ( )no how many
( ) RHU ( ) Private hospital/clinic ( ) government hospital hours/min.______________________
( ) albularyo others(specify)__________________
 COMMUNITY AS A SOCIAL SYSTEM

13. Combined Monthly family income (Buwanang kita ng Pamilya)

( ) P1,000 and below
( ) P1,001-P5,000
( ) P5,001-P10,000
( ) P10,001- P15,000
( ) P15,001-P20,000
( )P20,0001-P25,000
( ) P25,001-P30,000
( ) P30,001 and above

14. Other sources of Income (livelihood)

( mayroon pa bang ibang pinagkukunan ng kabuhayan)
( ) yes ( ) no
if yes, what ? Kung mayroon, ano ito?
( ) sari sari store ( ) poultry raising ( ) livestock raising
( ) craft making ( ) others (specify)______________

15. Monthly family expenditure (buwanang gastusin ng pamilya)

( ) P1,000 and below
( ) P1,001-P5,000
( ) P5,001-P10,000
( ) P10,001- P15,000
( ) P15,001-P20,000
( )P20,0001-P25,000
( ) P25,001-P30,000
( ) P30,001 and above

16. Priority expenditure, rank 1-7 (1 is the highest;7 is the lowest)

______ food (pagkain)
______ health (kalusugan)
______ house rental (upa sa bahay)
______ Education ( edukasyon)
______ Clothing ( damit)
______ water bill (bayarin sa tuibig)
______electric bill (bayarin sa kuryente)

17. Resources alloted for healthcare

(nakalaang pondo para sa kalusugan)? ( ) Yes ( ) No
If yes, from where? (kung oo saan galing)
( ) health insurance ( ) SSS/ GSIS ( ) PhilHealth ( ) savings
( ) others (specify)______________

B. Political / Leadership Aspect

18. Recognized Leaders in the community

( unang taong kinukunsulta at kinikilalang ninuno sa komunidad)
( ) Barangay Officials ( ) religious leaders ( ) elders
( ) non-government organizations ( ) others (specify)______________

19. Community Program

( Ano ang mga alam na programa sa komunidad)
( ) aware ( ) unaware
( ) peace and order ( ) aso ko tali ko ( ) curfew
( ) tapat ko linis ko ( ) Liga sa barangay
( ) others (specify)______________

20. Predominant Organizations in the Community

(kilalang samahan sa komunidad)
( ) barangay council ( ) sanguniang kabataan
( ) couples for christ ( ) Senior Citizens Club
( ) others (specify)______________
( ) member ( ) non member

21. Traditions celebrated / observed in the community

(tradisyon idinaraos / ipinagdiriwang sa kominidad)
( ) fiesta ( ) Holy week
( ) others (specify)______________

C. Environmental Aspect
22. Land Ownership ( Pagmamay-ari ng lupang tinitirahan)
( ) owned ( ) rented ( ) lease to own ( ) rent free

23. House ownership ( pagmamay ari mng bahay na tinitirhan)

( ) owned ( ) rented ( ) lease to own ( ) rent free

24. Type of materials used for house ( uri ng bahay na tinitirhan)

( ) light ( ) strong ( ) mixed ( ) makeshift ( barong barong)

25. Ventilation
( ) well ventilated ( )fair ( ) poorly ventilated
(Requirement: openning of 10% floor area)
26. Lighting-facilities
( ) electricity ( ) kerosene ( ) candles
( ) others (specify)______________
( ) adequate ( ) inadequate

27. Furniture / appliances (specify);____________________

___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________

28. Source of Information

( ) radio ( ) newspaper
( ) TV ( ) others (specify)______________

29. Accident hazards:

( ) persons and medicines improperly kept
( ) pointed / sharp object improperly kept
( ) fire Hazard
( ) fall hazard
( ) brecheen stairs
( ) others (specify)______________

30. Excreta Disposal

( ) pail system
( ) open pit
( ) open pit with cover
( ) water- sealed
( ) water- sealed

31. Ownership of toilet facility ( pagmamay-ari ng palikuran)

( ) private (sariling gamit)
( ) shared ( may kahati sa gamit)
( )public (gamit pambayan)

32. Sewage System in the community (uri ng kanal sa komunidad)

( )blind drainage
( ) open drainage
( ) none
( ) mosquitoes (lamok)
( ) others (specify)______________

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

( ) free flowing ( ) stagnant

34. Type of waste disposal used ( uri ng pagtatapon ng basura)

( ) animal feeding
( ) composting
( ) others (specify)______________

( ) open dumping ( ) burial pit

( )burning ( ) Garbage collection (DPS)

35. Container used for garbage

( ) garbage bag ( ) waste basket ( )sack ( )none
_____ covered _____uncovered

36. Source of drinking water (pinanggagalingan ng inuming tubig)

( ) Commercially prepared water ( ) Deep well
( ) local water system ( ) rain water ( ) artesan well
( ) streams, rivers, springs
Distance from the supply of water: _____________________

37. Storage of drinking water ( imbakan ng inuming tubig)

( ) jar (banga) ( ) plastic / glass container
( ) bottles ( ) drum ( ) water tank
( ) water dispenser _____ covered _____uncovered

38. Method commonly used in sanitizing water

(paraan ng paggamit ng upang mapanatiling malinis ang inuming tubig)
( ) boiling (pagpapakulo ( ) filtration (pagsasala)
( )sedimentation (pagpapalatak) ( ) others (specify)______________

39. Domestic Animals upkeep (dogs and cats including livestocks)

Vaccination
Kind Number Place kept (Bakuna sa
(Uri) (Bilang/ dami) (kinalalagyan) Hayop)
w/ w/o
40. Presence of Vectors and rodents (pagkaroon ng peste sa bahay)
( ) flies (langaw)
( ) termites (anay)
( ) rats (daga)
( ) roaches (ipis)
( ) mosquitoes (lamok)
( ) others (specify)______________

41. Presence of breeding sites of vectors ( pagkakaroon ng -

lugar na pinmama hayan ng mga peste)
_____ with _____ without

if with, pls specify location: _______________________________

( ) flies (langaw)
( ) termites (anay)
( ) rats (daga)
( ) roaches (ipis)

42. Ways of controlling vector ( paraang ginagawa upang mapuksang mga peste sa bahay)
( ) cleaning (paglilinis)
( ) fumigation (pagpapausok)
( )insecticide (pamatay insekto)
( ) fly traps
( ) mouse traps
( ) screen on doors and windows
( ) others (specify)_______________________

HEALTH ASPECT

43. Community health programs ( programang pangkalusugan )

Aware Utilizes
(alam) (nagkukunsulta)
( ) free consultation ( libreng konsulta) ________ ________
( ) Immunization (libreng bakuna) ________ ________
( ) Family Planning (pagplano ng pamilya) ________ ________
( ) Pre-natal check up ( para sa buntis) ________ ________
( ) well-baby clinic (para sa mga sanggol at bata) ________ ________
( ) others (specify) _______________________

44. First person consulted in times of illness

(unang taong kinukunsulta tuwing may nagkakasakit)
( ) doctor
( ) nurse
( ) midwife
( ) BHW
( ) relatives/ family
( ) albularyo/ faith healer/ Hilot
( ) others (specify) _________

44 . Medication taken during illness (gamot na iniinom)

( ) prescribed ( ) herbal ( ) over the counter
( ) others (specify)

45. Pag- gamit ng Family Planning:

Name Age Acceptor Non

Acceptor
If acceptor pls specify:
A. Natural
( ) rhythm
( ) cervicsl mucus method
( ) withdrawal

B. Artificial
( ) condom
( )IUD
( ) pills
( ) others (specify) _______

C. PERMANENT:
( ) Vasectomy
( ) Tubal Ligation
( ) others (specify) _________

NUTRITION

46. Eating / feeding habits / practices

( ) skip meals
( ) 3 meals a day
( ) 3 meals w/ snacks

47. Food usually eaten (madalas kinakain)

( ) fish
( ) meat
( )vegetable
( ) mixed

48. Food Storage practices ( pangangalaga sa pagkain)

( ) refrigerator ( ) table ( )basket ( ) others_____________ _____ covered _____Uncovered

49. Food source

( )backyard garden & poultry ( ) market
( ) sari sari store ( ) ambular vendo
For items 49-51 Answer only if applicable
50-51 - if there are children 0-12 months in the family
52 - if there are children 0-83 months ( 0-7 yrs) in the family
50 - if there is a preganant member of the family

49. Infant Feeding program

( ) breastmilk ( ) commercially prepared milk ( ) mixed
If commercially prepared:
________ condensed Milk _______ Evaporated Milk
________ powderd Milk ( ) others (specify)_________

50. Maternal Care (Pangangalaga sa mga buntis

Age of Gestation (Bilang Expected date of Delivery TT immunization Laboratories

Pre-natal Check up
No. Of ng buwan ng (Inaasahang petsya ng
Name (Pangalan)
Pregnancy pagbubuntis) panganganak)
DAYS ( MOS) mm-dd-yyyy 1ST TRI 2ND TRI 3RD TRI
w/ w/o w/ w/o
(1) (1) (2)

51. Immunization Status of target Age Group (0-12 months)

OPV PENTA AMV

Remarks
HEP- B
Completely Fully
Name in mos. BCG Vaccine
1 2 3 1 2 3 1 2 immunized immunized
child child (FIC)
52. Nutritional Status for children (0-83 months)

Age in
Date of weighing Vitamin A
Date of Birth Months Weight Remarks
Name (Pangalan) (Petsa ng pag Deworming supplementation
(Kapanganakan (edad) (Timbang)
timbang)

53. Morbidity
Consultation Intervention (Medication) If with medication specify
Name (Pangalan) Age Sex
(edad) (Kasarian) With Without With Without