OLIVAREZ COLLEGE

Dr. A. Santos Avenue, San Dionisio, Parañaque City

PACUCOA Accredited
COLLEGE OF HEALTH SCIENCES EDUCATION
NURSING DEPARTMENT

FAMILY SURVEY QUESTIONNAIRE

I FAMILY COMPOSITION AND SOCIO-ECONOMIC CULTURAL FACTORS

Head of the Family : _____________________________________ Date of survey: _________________________

Address : __________________________________________________ Barangay: ______________________________
Length of residence:______________________________________ Household Number:____________________

Family Structure: ( )Nuclear ( )Extended ( )Cohabitating ( )Blended ( )Single Parent

Family Size : ( )Small ( )Medium ( )Large

Household Member
Name Gender Age Civil Relation to the Religion Ethic Educational Employment Monthly
Status Family Head Background Attainment Status Income
Monthly Expenses

Item Amount

Food (meat, vegetable, others) Php

Clothes (ukay - ukay, dept. store)

Shelter (rental & maintenance)

Health (check -up)

Education

Electricity

Water (general purpose, drinking)

Leisure

Others

Decision Maker
A. Home ( ) Father ( ) Mother ( ) Both ( ) Others

B. Education ( ) Father ( ) Mother ( ) Both ( ) Others

C. Health ( ) Father ( ) Mother ( ) Both ( ) Others
II. Home and Environmental Factors
1. HOUSING
A. Land Ownership ( ) Owned with title ( ) Land tenant ( ) Informal settlers ( ) Others ________
B. House Ownership ( ) Owned ( ) Renting ( ) Rent free ( ) Others ________
C. Housing Material ( ) Concrete ( ) Wooden ( ) Mixed ( ) Light materials
D. Housing Structure ( ) Bungalow ( ) Row Houses ( ) Single detached ( ) Apartment ( ) Others ______
(1 storey) ( 2 storey)

E. No. of bedrooms ( ) None ( )1 ( )2 ( )3 ( ) Others ______

F. Lighting Supply ( ) Electricity ( ) Kerosene ( ) Petromax ( ) Others _____

G. Ventilation : Rate _______________________ H. Sanitation: Rate________________________

RATING SCALE

8 = EXCELLENT
6 -7 = VERY SATISFACTORY
4 -5 = SATISFACTORY
0 - 3 = POOR

a. Person that can pass the door ( ) 0 ( ) 1 ( ) 2 a. Presence of insects ( ) 0 none ( ) 1 Some ( ) 2 Too
many to count
b. No. of exit ( )0 ( )1 ( )2 b. Cleanliness (inside & outside) ( ) 0 ( )1 ( )2
c. No. of window ( )0 ( )1 ( )2 c. Presence of odor ( )0 ( )1 ( )2
TOTAL : ___________ TOTAL : ___________
2. KITCHEN
a. Cooking Facilities ( ) Electric Stove ( ) LPG ( ) Kerosene ( )Charcoal ( ) Others ________
b. Food Facilities
1. Storage ( ) top of table w/ cover ( ) Food cabinet ( )Refrigerator ( ) Exposed (hanging, table w/o cover)
2. Preparation ( ) Home prepared ( ) Bought ( ) both ( ) Others ________
3. Food Sanitation Rating : _______________________
a. Observed proper hygiene ( )0 ( )1 ( )2

b. Clean kitchenware used ( )0 ( )1 ( )2

c. Portable water source ( )0 ( )1 ( )2

d. Clean dining/cooking place ( )0 ( )1 ( )2

TOTAL : ________________________
3. WATER RESOURCE
a. Water Supply ( ) Delivered/Supplied ( ) Deep well ( ) Maynilad/NAWASA
b. Water Storage ( ) Container w/ cover ( ) Container w/o cover ( ) Others __________
c. Source of drinking water ( ) Deep well ( ) Maynilad/NAWASA ( ) Water Station
d. Method of purifying water ( ) Boiling ( )Chlorination ( )Sedimentation ( )None/direct from the water pipes

4. DRAINAGE FACILITY
a. Types of drainage ( ) Open ( ) Close ( ) Others __________
b. Flow of drainage ( ) Free flowing ( ) Stagnant

5. TOILET FACILITY
a. Type of toilet ( ) None ( ) Level 1 (Pit latrine) ( ) Level 2 (using dipper (tabo)/ pail) ( ) Level 3 (Conventional sewerage)
b. Ownership ( ) Owned ( ) Shared ( ) Others ____________________
c. Location ( ) Inside the house ( ) Outside the house ( ) Others ____________________
d. Sanitation
1. Presence of foul smell ( )0 ( )1 ( )2
2. Presence of Insect ( )0 ( )1 ( )2
3. Presence of stain ( )0 ( )1 ( )2
4. Maintenance ( )0 ( )1 ( )2

TOTAL : _______________________
 6. GARBAGE DISPOSAL

a. Method ( ) Burning ( ) Open dumping ( ) Collected ( ) Others __________

b. Container ( ) Covered ( ) Open ( ) No container ( ) Others __________

7. PRESENCE OF ACCIDENT HAZARDS

a. Domestic animals ( ) Dogs ( ) Cats ( ) Others _______________

1. History of vaccination ( )With vaccination ( ) Without vaccination

b. Presence of insects/rodents ( ) Yes ( ) No

c. Type of accident hazards ( ) Pointed/sharps edge objects ( ) Poisons & medicines within reach of children ( )wet floor
( ) Fire/fall hazards ( ) Exposed electrical wiring
III. HEALTH STATUS
a. Awareness of DOH- Programs

DOH PROGRAM YES NO

1.Family planning

2.Extended program of immunization

3. Dental Program

4. Maternal and child program

5. Under five clinic (operation timbang)

6.Control of diarrheal diseases

7. Control of active respiratory infection

8. Control of sexually transmitted diseases

9. Nutritional program

10. Dengue control program

11. Cancer control program

12.Control of cardiovascular diseases

13. Control of diabetes program

14. National tuberculosis control program

15. Leprosy control program

16. National mental health control program

17. Rabies control program

b. Health status of children under 8 years old

Name Age Place of birth Birth attendant Feeding pattern Present weight

c. Immunization status of children under 8 years old

Name Age BGC DPT1 DPT2 DPT3 DPT OPV1 OPV OPV3 OPV HEPA1 HEPA2 HEPA3 MEASLES PLACE REASONS FOR
2 OF INCOMPLETE
IMMUNI UNIMMUNIZE
ZATION D
CHILDREN
 d. INFANT FEEDING PRACTICE

1. Type of feeding practice ( ) breastfeed ( ) bottle,pls.specify____________________

e. FAMILY PLANNING METHOD USED

METHODS YES NO PROBLEM ENCOUNTERED

Calendar/ Rhythm

Body basal temperature

Lactational amenorrhea method

Withdrawal

Condom

IUD

Oral Contraceptive

Injectable

Tubal ligation

Vasectomy
 f. Pregnancy for the past few years

Name Age No. of No. of Prenatal Place of Tetanus toxoid Place of Delivered Problems
pregnancy delivery consultation Prenatal Immunization delivery by encountered
Check up during
pregnancy
labor and delivery

g. Morbidity (illness for the past 6 months)

Name Age Illness Place of consultation Treatment done

h. Mortality (causes of death for the past 1 year)

Name Age Gender Cause of death

i. Lifestyle

Lifestyle Age Gender How often/how long How many packs/bottles

Smoker

Alcohol

Drug abuse