UNIVERSITY OF SAINT LA SALLE

COLLEGE OF NURSING
BACOLOD CITY

COMMUNITY HEALTH NURSING

Community Health Profile Worksheet
(Worksheet “C”)

Part I: ASSESSMENT OF THE FAMILY

Mr. Lopez
Head of Family_________________________ 4
Family Number:____________

Hacienda Sto. Domingo Barangay Granada Bacolod City Negros Occidental

Address:________________________________________________________________
House No./Street Barangay Municipality Province

MEMBERS OF THE HOUSEHOLD

RELATION SEX BIRTHDAY AGE MARITAL STATUS/ HIGHEST

TO HEAD Month/day/y RELIGION EDUC
FAMIlY OCCUPATION
ear COMPLETED
MEMBER
No. TYPE
Name OF
PLACE
WORK
Hacienda
Sto.
Domingo,
Cecil February Roman
1 Wife F 20 Married Elementary Housewife Barangay
Lopez 20, 2001 Catholic
Granada,
Bacolod
City
2 Ryan July 08, Roman
Son M 3 Single
Lopez 2018 Catholic
3 Ryan March 6, 1 year and Roman
Son M Single
Lopez 2020 8 months Catholic

1. Types of Family Structure: Nuclear________ Extended___________

2. Family Size:
 Small (1-4 members)___________
 Medium (5-6 members)_________
 Large (7 members and up)_______

Part II. THE EIGHT SUBSYSTEMS:

I. HOME AND PHYSICAL ENVIRONMENT

1. Types of Dwellings:
 Concrete________________
 Wood _________________
 Concrete-wood___________
 Makeshift_______________
 Others: Please specify:______________________

2. Do you have a backyard? Yes_______ No_______

3. Residency/length of Stay:
 Month/s__________________

1
  Years____________________
 Others: Please specify_______________________
Since birth

4. House ownership:
 Owned_____
 Rented_____
 Rent-free_____
 Others: Please Specify____________
5. Land Ownership:
 Owned____
 Rented_____
 Squatter_______
 Others: Please Specify_______

6. Do you have domestic animals?

No_____ Yes_____, What are these?___________________

7. What kind of weather does your community usually have? ______________________

Sunny and rainy

8. Does your community experience natural calamities?

No______ Yes_____, What are these?_________________________________
Typhoon, flood, and earthquake

9. Where do you usually go if you experience these?________________________________

Stay inside our house

10. Are there reported cases of crimes in your community?

No_____ Yes____, What are these?___________________

11. Are there reported cases of drug addiction in your community?

No____ Yes___

12. Do you have electricity?

No____ Yes_____
13. Means of Cooking:
 Electric Stove________
 Wood______
 Charcoal_____
 Kerosene________
 LPG____________
 Others: Please Specify:________________________

II. EDUCATION:

1. Are there household members who are presently attending school?

Yes____________No__________

If yes, What level?______________________________________________

What is the name of the school?_____________________________________
Where is the school located?________________________________________
The children do not attend school yet and stay in the house with their mother.
If no, why?_______________________________________________________

2. Are there schools in the community?

Yes____ No___
Two Local High Schools (Emiliano Lizares National High School and
If yes, What are these?_____________________________________________________
Generoso Villanueva Sr. National High School- Primary Level and
__________________________________________________
Secondary Level)
______________

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3. What are the educational facilities of the school in your community?
__________________________________________________
School Clinics and School library

4. Is there a school clinic? Yes____No___

If no, why?_________________

5. What are the health services offered by the school nurse?

Deworming medications, Vitamin A supplements and other medical services
_________________________________________________________________
6. Do peoplesuch
goastowound
schooldressing
outsideand
thefirst aid.
community? Yes____ No___
` If yes, What school? ____________________________
7. Is there any nutrition program available in your school? Yes____ No___
If yes, What is this? ________________________
8. Are there night school in your community? Yes___ No___
If yes, What school?
Do you avail of this night school program? Yes_______ No ________________
Not safe and convenient for children having night school
If no, why?__________________________________________
9. Are there schools in the community for special children?Yes____No____
If yes, What school?__________________
_____________________________________
10. Are there vocational schools in the community? Yes___ No____
If yes, What school?___________________
______________________________________
11. Are there PTA’s in the school? Yes_____________ No_______________
Are you a member? Yes___________ No___________

III. SAFETY AND TRANSPORTATION

1. Food Storage:
 Refrigerator______
 Without refrigerator but with cover_______
 Others: Please specify_____________

2. Source of Drinking water:

Deep Well_____ Communal faucets____
Rain water_____ Distribution (pipeline)___
River/stream____ Purified Water
Others: Please specify__________________
Artesian Well_________

3. Storage of Drinking Water”

With cover________________ Without cover_________________
Container
What kind?_____________________________________________

4. Is the water safe for drinking? Yes______________ No____________

If no, what do you do before drinking the water?_______________________

5. Do you have your own drinking glass? Yes______________ No_________________

If no, why?_____________________________________________________

6. Do you have good quality of air in the community? Yes___________ No___________

If no, why?______________________________________________________

7. How do you dispose your garbage?

 Compost pit_____________
 Burning________________
 Collected_______________
 Open dumping___________
 Others: _________________

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8. Do you practice waste segregation? Yes _______________ No _____________
If no, why?______________________________________________
It helps us save money by using only 1 plastic bag

9. Do you have a toilet? Yes____________ No______________

 Pit privy____________
 Water sealed________
 Septic Tank_________
Flush type
 Others: Please specify________________________
 If no, why?_________________________________

10. Are there barangay tanods in the community? Yes_____________ No _______________

11. Are there public transportations available in the community? Yes_____ No___
If yes, what are these?_______________________________________________
Jeepney, motorcycle, and tricycle
If no, why?________________________________________________________

12. Is there a fire station in the community? Yes_____________ No______________

2
How many fire trucks are available?______________________________

13. Are there Police outposts in the community? Yes ________ No _______________
If no, why?__________________________________________________

14. Who is/are the person/s responsible in resolving conflicts in the community?
Barangay Captain______
Tanod ________
Police________
Relative_____
Neighbors___________
Others: ______________
15. Is your community generally peaceful? Yes________ No______
If no, why?_______________________________________________

16. Are there household pest? Yes___________ No_____________

If yes, what are these?___________________________
Cockroach and ants

17. Using slipper on cockroaches and spraying water

How do you destroy the pests?________________________________________
with a little bit of Zonrox on the ants.
______________________________

IV. POLITICS AND GOVERNMENTS

1. Do you know your purok leader? Yes__________________ No________________

If yes, What is his/her name? ____________________________________
Luisito Tabujara
If no, why? ____________ _____
2. Do you know your barangay captain? Yes_____ No____
If yes, What is his/her name?____________________________________
Alfredo Talimodao
If no, why?_______________________________________________
3. Do you exercise suffrage during election? Yes_____ No____________
If no, why?_______________________________________________
4. Do you have peaceful elections in your community? Yes_______ No_________
If no, Why?________________________________________________
5. Are you a member of an organization, club, or association in your community?
Yes____ No ______
If yes, What organization/club/association?________________________
What is your position? ________________________________________
If no, why? _____________________________________________________
I think it’s better if we participate only since we don’t have time for that.
6. Where do you run to when you need help?
Barangay Captain_____ Priest/Ministers_____
Purok Leader_____ PTA President_____
Councilman_____ Landowners_____
Teachers_____ Club Officers ____

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 Others: Please specify;________________________________________

VI. HEALTH AND SOCIAL SERVICES:

1. Is there presently a sick family member? Yes ____ No _____

If yes, Name______________________ Age_____________ Sex _______________
Type of ailment_______________________________________________________
Duration of ailment?___________________________________________________
Is anybody attending the sick member? Yes _______________ No_______________
If yes, who is attending him/her?
 Doctor____________________
 Nurse_____________________
 Midwife___________________
 Herbolario_________________
 Others: Specify_____________
 None_________________
why?______________________________
2. Immediate dead family member? ___________________________________________
Cause of death__________________________________________________________
3. How often do your family members get sick?
 Once a year_____
 Twice a year_____
 Several times _____
 Others_________________________
4. Common ailments of the family during a year?
 Fever______
 Colds_____
 Flu______
 Diarrhea______
 Cough______
 Stomach Ache_____
 Toothache_____
 Others: Specify_________
5. Where do you usually go when you get sick?
BHS__________________
Private Clinic__________
Hospital_______________
Stay at home.
Others: ________________
6. Whom do you go to when you get sick?
Doctor ____
Nurse _____
Midwife_____
Herbolario_____
Others_________________
7. Over-the-counter medicine
What medicines do you usually take when you get sick?___________________________
(Paracetamol or Biogesic)
________________________

8. Are these medicines prescribed by doctors? Yes ____ No _____

If no, why? ___________________________________________________
There is no doctor in the Health Center most of the time and going
______________________
to the doctor is quite costly.
9. Do you have herbal plants in your backyard? Yes ___________ No ________________
If yes, what are these? _____________________________________________
Oregano and Alibhon Tree
If no, why? ______________________________________________________
10. For what ailments do you use them? _________________________________________
Cough and Diarrhea
11. Do you use a method in family planning? Yes ____ No ______
If yes, what method?_______________________________________________
If no, why?_______________________________________________________
Not interested.
12. From whom do you learn about the method/s in family planning?
 Neighbour______

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  Friend______
 Relative_____
 Midwife_______
 Nurse_______
 Doctor______
 Priest/Ministers_________________________
 Others: Specify__________________________
13. Whom do you consult when you are pregnant?
Doctor______
Nurse______
Midwife______
Trained hilot________
Untrained hilot______
Others: Specify________________
14. Were you given tetanus toxoid immunization? Yes _________ No __________
15. Where do you deliver your baby?
Home_______________________
RHU________________________
Private Clinic_________________
Hospital_____________________
Lying-In Bacolod Birth Center
Others: Specify________________________
16. Do you breastfeed your baby? Yes _________ N o _____________
If yes, for how long?
If no, why?______________________________________
To save money and my children like breastmilk
17. Do you give milk formula to your baby? Yes ____ No ____
If yes, what milk formula? ____________ for how long______________
If no, why __________________________________________________
To save money and my children like breastmilk
18. Do you give both milk formula and breastfeeding? Yes ________ No______
If yes, why?__________________________________________________
To save money and my children like breastmilk
If no, why?___________________________________________________
19. At what age do you give supplementary feeding to your baby?_________________
What kind of supplementary food?_______________________________________

20. How often do you eat the following food?

FOOD DAILY EVERYWEEK 2X A WEEK ONCE A ONCE A
WEEK MONTH
Vegetable
Fruits
meat/poultry
rice/rootcrops
legumes
fish

21. How many of your children are very thin_________, pale___________, with big
abdomen_____________, with skin disease ___________?
22. Do you submit your children for immunization? Yes _____ No _____
If yes, DPT____________
BCG____________
POLIO__________
HEPA B_________
MEASLES_______
HBS Ag__________
FLU_____________ Others: Specify _______________
23. Do you have Botika in your barangay? Yes ____________ No___________
If yes, Do you get your medicines from this botika?____________________
If no, why? ____________________________________________________
24. Do you have a hospital in the community? Yes __________ No___________
If yes, what is the name of the hospital ________________________
Do you avail of the services in the hospital? Yes_____ No ________
If yes, what are the services?________________________________
If no, why?______________________________________________
How do you get to the hospital?

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  Walk_________________
 Car__________________
 Jeep__________________
 Tricycle_______________
 Tricykad_______________
 Others: Specify__________

25. Do you have the following health care facilities/services in the community?
Clinical laboratory______________
Ultrasound Laboratory___________
Xray Laboratory________________
Others: Specify_________________
26. Do you avail of these services? Yes_________ No __________________
27. How do you get to these facilities?
Walk_________________________
Jeepney_______________________
Car___________________________
Tricykad_______________________
Tricycle _______________________
Others: ________________________
28. Do you avail of the services in the BHS? Yes__________ No______
If yes, What are these services?_____________
Immunization ___
How often do you avail of the services?
Very often__________________
Often______________________
Seldom____________________
Very Seldom________________
If no, why? ____________________________________________________
29. How do you get to the BHS?
Walk_____________________
Jeepney___________________
Car_______________________
Tricykad__________________
Tricycle___________________
Others:____________________
30. Who is the source of your health information?
Doctor______________
Nurse_______________
Neighbor____________
Herbolario___________
Others:______________

VI. COMMUNICATION:

1. Do you read newspapers? Yes _____________ No_____________

If yes, what newspaper?___________________________________
How often do you read?___________________________________
If no, why?_____________________________________________
We don’t have newspaper.
2. Aside from newspapers, do you read other printed materials? Yes _______ No______
If yes, what are these?___________________________________________________
How often do you read?__________________________________________________
If no, why?____________________________________________________________
We don’t have printed materials to read.
3. Do you listen to the radio? Yes ____________ No_______________________
If yes, AM____________FM_______________
How often do you listen?_____________
Everyday
If no, why?_____________________________
4. Do you watch television? Yes __________ No____________
If yes, What program? Name of Program/TV Network
News____________ ________________________
GMA and Kapamilya TV
Telenovela________ ________________________
Variety Shows_____ ________________________
Game Shows______ ________________________

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 Cartoons_________ ________________________
Talk Shows _______ ________________________
Others____________ ________________________
How often do you watch?__________
Seldom
If no, why?____________________

5. Do you have the following entertainment/communication facilities at home?

Television_________
Radio________
Computer with internet_________________
Computer without internet_______________
Telephone____________________________
Cellphone____________________________
Others _______________________________

6. 2
How many household members have cell phones? ______

7. Where do you usually use the cell phones/telephone?________________________

Everyday for communication

8. How do you contact in case of emergency?

Telephone__________________
Cellphone__________________
Both______________________

9. Do you have post office in the community? Yes______________ No__________

If yes, where is it located?_____________
Do you avail of the postal services? Yes ________ No________________

10. Do you have purok meetings? Yes___________ No_____________

If yes, do you attend the meetings?____________________
How often do you have the purok meetings?_____________
If no, why?______________________________________________
I am always away since I am working as a driver and my wife is
busy in the house.
_____________

11. Do you have the following communication facilities in the community?

Radio stations_______________
TV stations_________________
Telephone Company__________
Cell Sites___________________
Others: ______________________

VII. ECONOMICS:

1. P6,000 – 7,000
What is the family’s monthly income? __________________________

2. What are the family’s monthly expenses?

Budget Food Electricity House Clothes Water Health Education Leisure

P6000-7000 P4000 P450 P300 P300 P400 P1000
Total: P 6450.00

3. Do you have income generating projects? Yes___________ No____________

If yes, what? ___________________________
I don’t have enough money to start one.
If no, why? ___________________________

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VIII. RECREATION:

1. What are the recreational sites that can be found in your community?Outside the
community?_____________________________________________________________
No, there are no recreational sites outside the community.
Do you avail of these facilities? Yes ___________ No_____________
If no, why?______________________________________________________________
We don’t have enough money to avail these facilities.

2. Do you engage in any sport? Yes ______ No________

If yes, what sports?_____________________
If no, why?______________________________________________________________
I don’t have time since I’m busy working.

3. Does your community have any sports facilities? Yes___________ No___________

If yes, what sports facilities?_______________
If no, why?______________________________________________________________
No financial support.

4. Do you play any card or board games? Yes______ No___________

If yes, what game/s?___________________________________________________
If no, why?__________________________________________________________
Dama or Checkers

5. Do you have any tourist spots in your community? Outside the community?
Yes____ No_____
If yes, what is/are the name/s of the tourist spot/s?____________________________

6. Are there movie houses in the community? Outside the community? Yes______ No___
If yes, do you watch movie?_________________ How often?___________________
What kind of movie do you usually watch?___________________________

7. Are there Churches or religious services available in the community? Yes___ No____
If yes, what are the types of church and religious services?____________________
____________________________________________________________________

8. Do you participate in the church or any religious activities? Yes ____ No________
If no, why?_________________________________________________________
I’m away most of the time since my work is being a driver.

9. Do any churches provide recreational activities or facilities? Yes ______No_______

If yes, what activities/facilities?___________________

10. Are there social committees, organizations or clubs available in the community?
Yes___________ No___________
If yes, what are these organizations/clubs/committees?____________________
Are you a member of any of these?____________________________________

Mr. Lopez
Informant:________________ Kristil Marie E. Chavez SN-USLS
Surveyed by:________________________________