Western Mindanao State University

College of Nursing

COMMUNITY HEALTH ASSESSMENT TOOL

Respondent__________________________________________________________________________ Age____________________

Status_________________________________________________________________________________ Sex ____________________

Relation to head______________________________________________________________________( if not head of the family)

1. FAMILY DATA

1. Head of the family_______________________________________________________________ Age___________________

Name of spouse__________________________________________________________________ Age___________________

2. Address__________________________________________________________________________ Mobile no.____________________________

3. Educational attainment
Husband__________________________________________________________________________
Wife ______________________________________________________________________________

4. Length of residency ______________________________________________________________

5. Ethnic origin ______________________________________________________________________
6. Type of family: ( ) Nuclear ( ) extended ( ) Others_____________________________

7. Members of the household

Name Age Sex Educational attainment Occupation

11. SOCIO-ECONOMIC DATA

1. Source of income
Husband______________________________________________________ Wife ________________________________________________________

Monthly income: ( ) Below P2,000 ( ) P 2,000-P5,000 ( ) P5,001-P8,000 ( )More than P8,000

2. Family expenditures
 Food: ( ) Below P50 ( ) 50-75 ( ) More than P70 , If more than ,How much________________________________
 Clothing: no. of times buying ( ) Once a year ( ) Twice ( ) Thrice ( ) others ________________________________
 Schooling ( ) public ( ) Private ( ) Others_______________________________________
111. HOUSING AND ENVIRONMENTAL CONDITION

1. Home:
 Ownership ( ) Owned ( ) Rented ( ) Others_________________________________________

 Construction materials used ( ) Concrete ( ) Wood ( ) Mixed ( )Others__________________________

 Number of rooms used for sleeping ___________________

 Ventilation: ( ) Poor ( ) Good

 Lighting Facilities: ( ) Electricity ( ) Kerosene ( ) Others__________________________________________

 General Surroundings: ( ) Clean ( ) Dirty

2. Water supply: Source: ( ) Artesian well ( ) Deep well ( ) NAWASA ( )0thers_________________________________

 Storage of drinking water: ( ) Covered ( )Uncovered( )Refrigerated ( )Others_______________________________
 Containers used ( ) Plastic ( ) Bottles ( ) Clay jar
 Sanitary condition__________________________________________________________________________________________________

3.Cooking facilities ( ) Electric stove ( ) Gas stove ( ) Firewood/Charcoal

 Sanitary condition_________________________________________________________________________________________________

4.Drainage facility: ( ) Open ( )Blind ( )None

5.Garbage Disposal
 Container: ( ) Covered ( ) Open ( ) None
 Method of disposal: ( ) Garbage collection ( ) Open burning ( ) Open dumping ( ) Burial pit
 ( ) Others,____________________________________________________________________

6. Toilet facility
 Sanitary: ( ) Flush type ( ) Pit privy/Communal ( ) With septic
 Ownership: ( ) Owned ( ) Shared
 Unsanitary: ( ) Ballot system
 ( ) Others,____________________________________________________

7.Presence of domestic animals

Kind Number Where kept

8.Pest/insect: ( ) Mosquito ( ) Lizard ( ) Flies ( ) Cockroach ( )Rats ( )others__________________________________

IV. NUTRITION
1. Food preference: ( ) Meat ( ) Fish ( ) Fruits/Vegetables ( )Mixed
2. Common fare: ( ) Rice and egg ( ) Rice and Noodles ( )Rice and sardines ( )Others ____________________
3. Food storage: ( ) Covered ( ) Uncovered ( ) Refrigerated ( ) Others____________________________________
4. Backyard Gardening: ( ) Fruit bearing ( ) Vegetables ( ) Herbal ( )Others_________________________________
5. Presence of nutritional disorder:
Goiter: ( ) Enlargement of the neck ( )Hoarness ( ) Dysphagia ( ) Others_________________________________
Anemia: ( ) Pallor ( ) Body weakness ( ) Easy fatigability
Vitamin A deficiency: ( ) Night blindness ( ) Pilak sa mata ( ) Others______________________________________

V. KNOWLEDGE, ATTITUDE AND PRACTICE

1. Do you utilize your health center? ( )Yes ( )No ,

If No, Why_____________________________________________________________________________________________________
2. Reason for utilizing health center:
( ) Illness ( ) Family planning ( ) Pre-Natal ( ) Post-Natal ( ) Immunization ( )Health counseling
( ) Others_____________________________________________________________________________________________________
3. Common illness encountered within 6 months in the family:
( ) Diarrhea ( ) Flu ( ) Dengue ( ) Pneumonia/Tuberculosis ( ) Others______________________________
4. What do you do for this condition? ( ) Self-medication ( )Consultation
5. First person consulted in times of illness: ( ) M.D. ( )Midwife ( )Nurse ( )BHW ( ) Herbularyo

6. Usual illness in the family

VI. COMMUNITY RESOURCES

1. Health and other facilities: ( ) School ( )Park ( ) Church ( )Market ( )Others______________________________

2. Sources of health funds: ( ) Government ( ) NGO’s/PO’s ( ) Private ( )Others _____________________________
3. Environment

Kind of neighborhood

Social and Health Facilities available

Communication and Transportation available

Assessed by: Date__________________________________________

___________________________________________ __________________________________________________
Student’s signature over printed name Signature of respondent over printed name

Reference:
WMSU-CN Manual COPAR: Vicenta T. Escobar, RN,MN,DPA Miriam Omar Kanti, RN, MN,DPA
COPAR Manual, Laguna Polytechnic University
Prepared by; Noted by;

Ernesto Joel D. Santos, RN, MN Anna Lizza S. Caburnay, RN,MAN

Clinical Instructor Coordinator, Level 11

Approved by;

Nursia M. Barjose, RN, DSN

Dean