VIRGEN MILAGROSA COLLEGE

UNIVERSITY OF
FOUNDATION NUSING

Head of the Family (Kinikilalang Puno ng Pamilya) ***Initials only_______________________________________________________ Control No: __________________________________________________

Complete Address: ________________________________________________________________________________________________ Surveyed By: _________________________________________________

Length of Residency (Tagal ng Paninirahan sa Lugar) : _________________________________________________________________ Date: ________________________________________________________

Place of Origin (Lugar ng Pinagmulan): ______________________________________________________________________________

Ethnic Background (Etnikong grupo na kinabibilangan) : _______________________________________________________________

Primary Dialect Spoken(Pangunahing dialektong ginagamit): ____________________________________________________________

COMMUNITY AS A PEOPLE

FAMILY STRUCTURE, CHARACTERISTICS, AND DYNAMICS

Education Occupation
(Antas ng Edukasyon) (Hanapbuhay)
*7 yrs old. & above *15-64 yrs. old
Highest Educational
Attaintment
Relationship (Pinakamataas na antas ng
to the head of edukasyong natapos)
Name of Household Members Occupational
the family
(Pangalan ng miyembro ng pamilya) Status
(Kaugnayan Gender Date of Birth Age Civil Status Religion Type Place (Kalagayan ng
sa puno ng (Kasarian) (m-d-yr) (Edad) (Estado Sibil) (Relihiyon) (Uri) (Lugar) trabaho)
pamilya) (Kapanganakan) *15 yrs. & above

1.

2.

3.

4.

5.

6.

7.

8.
 VIRGEN MILAGROSA COLLEGE
UNIVERSITY OF
FOUNDATION NUSING

S-single C-catholic EG-Elementary Grad

M-married P-protestant EU-Elem Undergrad
W-widowed SA-7th day adventist HG-High School rad
SEP-separated INC-iglesia ni cristo HU-High School undergrad
A-Annuled CU-College undergrad CU-College Undergrad
JW-jehova’s witnesses CG-College Graduate *specify highest educational attainment
Others PG-Post Graduate *specify highest educational attainment
PBD-Post Bachelorette Degree *specify highest educational attainment

COMMUNITY AS A SOCIAL SYSTEM e. Resources allotted for health care ( ) Couples for Christ
(nakalaang pondo para sa kalusugan) ( ) Seniors citizen club h. Ownership of toilet facility (pagmamayari ng
A. ECONOMIC ASPECT ( ) yes ( ) no ( ) Others, pls. specify: palikuran)
a. Combined monthly family income If yes, from where? (kung oo, galing saan?) _____________________________ ( ) private (sariling gamit)
(Buwanang kit ang pamilya) ( ) Health insurance ( ) SSS, GSIS ( ) shared (may kahati sa gamit)
( ) P1,000 and below ( ) P15,001 - P20,000 ( ) Phil. Health ( ) savings C. ENVIRONMENTAL ASPECT ( ) public (gamit pambayan)
( ) 1,001 - P5,000 ( ) P20,001 - P25,000 ( ) others, pls. specify: a. Land ownership (pagmamayari ng lupang tirahan)
( ) P5,001 - P10,000 ( ) P25,001 - P30,000 ___________________________________ ( ) owned ( ) rented i. Sewage system of the family (Uri ng kanal ng
( ) P10,001 - P15,000 ( ) P30,001 and above ( ) rent free ( ) lease to own pamilya)
( ) Others, pls. specify: ______________________ ( ) blind drainage ( ) open drainage
b. Other sources of income (livelihood) ( ) none
(mayroon pa bang ibang pinagkukunan ng b. House ownership (pagmamayari ng bahay tirahan)
kabuhayan?) ( ) owned ( ) rented j. Condition (kalagayan ng daloy ng tubig sa kanal)
*indicate the profit earned then add to the monthly ( ) rent free ( ) lease to own ( ) free flowing ( ) stagnant
income ( ) Others, pls. specify: __________________
( ) Yes ( ) No k. Type of garbage disposal used (Uri ng pagtatapon
If yes, what? (Kung mayroon, ano?) c. Type of materials used for the house (uri ng ng basura)
( ) sari-sari store ( ) poultry raising materyales ng bahay) ( ) animal feed ( ) composting
( ) craft making ( ) livestock raising ( ) light ( ) mixed ( ) open dumping ( ) burial
( ) Others, pls. specify: ( ) strong ( ) makeshift (barong barong) ( ) burning ( ) garbage collection
______________________________________ B. POLITICAL / LEADERSHIP ASPECT ( ) Others, pls. specify:
a. Recognized leaders in the community (unang taong d. Ventilation _____________________________
c. Monthly family expenditures (Buwanang kinunsulta at kinikilalang puno ng komunidad) ( ) well ventilated ( ) fair ( ) poorly ventilated
gastusin ng pamilya) ( ) Barangay officials ( ) Religious leaders (Requirement: opening 10% of floor area in sq.m.) l. Waste garbage segregation
( ) P1,000 and below ( ) P15,001 - P20,000 ( ) Non-gov’t organizations ( ) elders ( ) yes______ ( ) no ______
( ) 1,001 - P5,000 ( ) P20,001 - P25,000 ( ) Others, pls. specify: e. Lighting - facilities
( ) P5,001 - P10,000 ( ) P25,001 - P30,000 _____________________________ ( ) electricity ( ) kerosene ( ) candles m. Container used for garbage
( ) P10,001 - P15,000 ( ) P30,001 and above ( ) Others, pls. specify: _______________________ ( ) garbage bag
b. Community Program (Ano ang mga alam na __________ adequate __________ inadequate ( ) waste basket
d. Priority expenditures, rank it 1 - 7 (1 is the programa sa komunidad?) ( ) sac
highest, 7 is the lowest) ( ) peace and order ( ) fumigation f. Excreta Disposal (Uri ng palikuran) ( ) none
_______ food (pagkain) ( ) curfew ( ) tapat ko, linis ko ( ) pail system ( ) open pit ______ covered ______ uncovered
_______ health (kalusugan) ( ) sportsfest ( ) flush type ( ) closed pit
_______ house rental (upa sa bahay) ( ) Others, pls. specify: ( ) bored hole latrine ( ) water-sealed n. Source of drinking water (pinanggagalingan ng
_______ education (edukasyon) _____________________________ ( ) overhung latrine inuming tubig)
_______ electric bill (bayarin sa kuryente) ( ) commercially prepared water
_______ (clothing) c. Predominant organizations in the community ( ) deep well ( ) artesian well
_______ water bill (bayarin sa tubig) (Kilalang samahan sa komunidad) ( ) local water system ( ) rain water
( ) Barangay council g. Sanitary Condition of toilet facility ( ) streams, rivers, or spring
( ) Sangguniang barangay ( ) good ( ) fair ( ) poor
 VIRGEN MILAGROSA COLLEGE
UNIVERSITY OF
FOUNDATION NUSING
( ) Others, pls. specify: _____ for how long? (gaano katagal?) ( ) flies (langaw) ( ) termites (anay) ( ) Others, pls. specify:
_____________________________ ( ) filtration (pagsasala) ( ) rats (daga) ( ) mosquitos (lamok) _____________________________
( ) sedimentation (pagpapalatak) ( ) roaches (ipis)
o. Storage of drinking water (imbakan ng inuming ( ) Others, pls. specify: _____________________________ ( ) Others, pls. specify:
tubig) _____________________________
( ) jar (banga) ( ) plastic / glass container q. Domestic animal upkeep (dogs and cats only)
( ) bottles ( ) drum Kind Number Place kept Vaccination s. Presence of breeding sites of vectors
( ) water tank ( ) water dispenser (uri) (bilang) (pinaglalag (Bakuna sa hayop) (Pagkakaroon ng lugar na pinamamahayan ng
______ covered ______ uncovered yan) With Without mga insekto)
(Mayroo (Wala) ( ) with ( ) without
n) If with, specify location
____________________________

t. Ways of controlling of vectors (paraang ginagawa

upang umiwas ang mga insekto sa bahay)
( ) fumigation (pagpapausok)
p. Method commonly used in sanitizing water ( ) mouse trap
(Paraang ginagamit upang mapanatiling malinis r. Presence of vectors and rodents (pagkakaroon ng ( ) fly traps
ang inuming tubig) insekto sa bahay) ( ) insecticides (pamatay insect i.e. katol)
( ) boiling (pagpapakulo) ( ) screens on doors and windows (i.e. kulambo)
D. HEALTH ASPECT Changes clothes ( ) other, pls. specify: _____________________________
a. Community health programs (programang pangkalusugan) _____ covered _____ uncovered
Aware Utilizies
(alam) (nagkukunsulta) Eats balanced e. First person consulted in times of illness (unang taong kinukunsulta
diet tuwing may magkasakit)
Free consultation Smoking ( ) doctor ( ) albularyo
(libreng konsulta) _______ _______ ( ) midwife ( ) relatives
Immunization ( ) nurse ( ) faith healer
(libreng bakuna) _______ _______ ( ) family ( ) BHW
Regular exercise
Family planning ( ) hilot
(programaa sa pagpa- ( ) other, pls. specify: _____________________________
plano ng pamilya) _______ _______
Pre-natal check – up Use of f. Medication taken during illness (gamut na iniinom)
(programa para sa prohibited drugs ( ) prescribed ( ) herbal ( ) over the counter
buntis) _______ _______ Dental check – ( ) other, pls. specify: _____________________________
Well – baby clinic up
(konsulta para sa mga Drinking g. Method of family planning (pagpaplano ng pamilya)
sanggol na bata) _______ _______ alcoholic *applicable to members of reproductive age
beverages (15 – 44 yrs. old)
b. Family Health Practices Medical check – Name Ag Acceptor Non – Method
up e accepto
Recreational r
Health Practiced Not Frequency relaxation 1.
Practices practiced activities
Use of hygienic 2.
products
Sleep 6 – 8 3.
hours 4.
Brushes teeth c. Food usually eaten (madalas na kinakain)
*majority of the family members 5.
( ) fish
( ) meat 6.
Cuts toenails
( ) vegetable 7.
( ) mixed
( ) others, pls. specify: _____________________________ 8.
Cleans ears
d. Food storage practices (pangangalaga sa pagkain) Legend:
( ) refrigerator ( ) table ( ) basket r – rhythm
 VIRGEN MILAGROSA COLLEGE
UNIVERSITY OF
FOUNDATION NUSING
b – basal ( ) condoms ( ) IUD ( ) pill ( ) evaporated milk
body ( ) others, pls. specify: _____________________________ ( ) powdered milk
temp ( ) Others, pls. specify: _____________________________
c – cervical g.3. Permanent
mucus ( ) vasectomy
method
( ) tubal ligation

*for items h-k: answer only if applicable

 h and i – if there are children 0 – 12 mos. In the family
 j – if there are children 0 – 83 mos. (0 – 7 yrs ) in the
family
 k – if there is a pregnant member of the family

g.1. Natural h. Infant feeding programs

( ) rhythm ( ) cervical mucus method ( ) breastfeeding
( ) withdrawal ( ) formula
( ) basal body temperature ( ) mixed
( ) others, pls. specify: _________________ ( ) others, pls. specify: _____________________________

g.2. Artificial contraceptives Formula used:

( ) condensed milk

i. Maternal care (pangangalaga sa buntis)

Name ( pangalan ) No. of pregnancy Expected dare of delivery Prenatal Tenanus toxoid immunization
(bilang ng (inaasahang petsa ng check – up *indicate how many dosage
panganganak) Age of gestation (bilang ng panganganak)
buwan ng pagbubuntis)
1. With Without TI1 TI2 TI3 TI4 TI5
2.
3.
4.
5.
6.

j. Immunization Status of target age group (0 – 12 mos.)

Name Age of mos. BCG DPT OPV Hepatitis B AMV Remarks

Incomplete Complete Fully
(applicable to (applicable immunized
0 – 12 mos.) to 0 – 9 (applicable
1 2 1 2 3 1 2 3 mos.) to 0 – 12
mos.)
1.
2.
3.
 VIRGEN MILAGROSA COLLEGE
UNIVERSITY OF
FOUNDATION NUSING

4.
5.
6.

k. Morbidity (w/in 1 whole year) * Jan 1 – Dec 31

Name Age Sex Intervention

(pangalan) (edad) (kasarian) (medication/ hospitalization)
1. With Without
2.
3.
4.
5.
6.

l. Mortality (w/in 1 whole years) * Jan 1 – Dec 31

Name Age Sex Cause of death
(pangalan) (edad) (kasarian) (dahilan ng pagkamatay)
1.
2.
3.
4.
5.
6.

m. Blood pressure (18 yrs. & above)

Name Age Sex BP reading Familial history of hypertension Risk Factors

(pangalan) (edad) (kasarian)
Diet Exercise Smoking Alcohol
(high fat/ high salt) drinking
1.
2.
3.
4.
5.
 VIRGEN MILAGROSA COLLEGE
UNIVERSITY OF
FOUNDATION NUSING

6.