COMMUNITY HEALTH ASSESSMENT FORM
Respondent: __________________________________________ Age: _________ Gender: ________
Relation to Head (If not the Head of the Family): _________________________________________________
I. FAMILY DATA
a. Head of the Family: Age:
b. Name of Spouse: Age:
c. Address: Telephone No.
d. Educational Attainment e. Length of Residency: f. Ethnic Origin:
Husband [ ] College [ ] High School [ ] Elementary g. Family: h. Religion:
Wife [ ] College [ ] High School [ ] Elementary [ ]Nuclear [ ] Extended i. No. of Children
j. Members of the Household:
Name Age Sex Status Education Occupation
II. SOCIO-ECONOMIC DATA
a. Source of Income
Occupation: Wife __________________________ Husband _____________________________
[ ] Employed [ ] Unemployed [ ] Self-employed
Monthly Income:
[ ] Below ₱ 2,000 [ ] ₱ 2,000 - ₱ 5,000 [ ] ₱ 5,001 - ₱ 8,000 [ ] more than ₱ 8,000
b. Family Expenditures
1. Food [ ] Below ₱ 50 [ ] ₱ 50 – 75 [ ] More than ₱ 70
2. Clothing number of times of buying [ ] Once a year [ ] Twice a year [ ] Thrice a Year
3. Housing [ ] Water [ ] Electricity [ ] Telephone
4. Schooling [ ] Public [ ] Private
5. Others: _______________________________________________
c. Housing and Environmental Condition
A. Home
Type: [ ] Concrete [ ] Wood [ ] Mixed [ ] Makeshift [ ] Others:_________________
Ventilation: [ ] Poor [ ] Good
Lighting: [ ] Adequate [ ]Inadequate
Surroundings: [ ] Clean [ ] Dirty
B. Source of Water Supply
[ ] Artesian Well [ ] Deep Well [ ] NAWASA [ ] Others:___________________
C. Storage of Drinking Water
[ ] Refrigerated [ ] Covered [ ] Others:_________________
Container used: [ ] Plastic [ ] Clay Jars [ ] Bottles [ ] Others:___________________
D. Toilet Facilities
Sanitary: [ ]Flush [ ] Pit Privy [ ]Others Owned [ ]Shared
Unsanitary: [ ] “Ballot” System [ ] Others:_____________________
E. Garbage Disposal
[ ] Collection [ ] Burning [ ] Burying [ ] Open Dumping [ ] Garbage Cans [ ] Others:_________________
F. Food Storage
[ ] Covered [ ] Uncovered [ ] Refrigerated
G. Presence of Animals
[ ]Dogs [ ]Cats [ ] Pigs [ ] Others:________________________
H. Backyard Gardening
[ ] Vegetables [ ]Herbal [ ]Fruit-bearing [ ] Others:________________________
d. Community Resources
A. Health and Other Facilities
[ ] Health Center [ ]Park [ ] Public Hospital
[ ] Barangay Hall [ ] Market [ ] Church
[ ] School [ ] Health Center [ ] Private Clinic
B. Indigenous Health Workers
[ ] trained “hilot” [ ] “Herbularyo” [ ] Others: __________________________________
[ ] BHW [ ] untrained “hilot”
C. Sources of Health Fund
[ ] Government [ ] Private [ ]NGOs/POs [ ] Others:______________________________________
e. Nutrition
A. Food Preference
[ ] Fish [ ] Fruits/Vegetables [ ]Meat [ ] Mixed
B. Common
[ ] Rice and Egg [ ] Rice and Sardines [ ] Rice and Noodles [ ] Others: _________________________
C. Presence of Nutritional Disorder
1. Goiter
Enlargment of neck []
Dysphagia []
Hoarseness []
Others:________________
2. Anemia
Pallor []
Easy Fatigability []
Body Weakness []
3. Vitamin A Deficiency
Night Blindbess []
“Pilak sa Mata” []
Others: ___________________
f. Knowledge, Attitude, and Practice
A. Do you utilize the health center: [ ] Yes [ ] No
If no, why?__________________________________________________________________________
B. Reason:
[ ]illness [ ]prenatal [ ] Family Planning [ ] Postnatal [ ]Dental [ ] Nutrition
C. First Person consulted in times of illness:
[ ]M.D [ ]Nurse [ ]Midwife [ ] “Hilot” [ ] “Herbularyo” [ ]BHW [ ] Others:_______________________
D. Usual Illness in the Family
_______________________________ _______________________________
_______________________________ _______________________________
_______________________________ _______________________________
What do you do for this condition?
[ ] Hospital [ ] Private Clinics [ ] Nursing [ ] Others:____________________
E. Other’s Diseases
[ ]TB [ ] Leprosy [ ] Skin Disease [ ] Hepatitis [ ]Others:___________________
F. Do you submit your children (0-12 months) for immunization?
Name of Child Birthday Immunization
___________________________ __________________________ __________________________
___________________________ __________________________ __________________________
___________________________ __________________________ __________________________
___________________________ __________________________ __________________________
___________________________ __________________________ __________________________
___________________________ __________________________ __________________________
___________________________ __________________________ __________________________
___________________________ __________________________ __________________________
BCG DPT OPV AM
G. Do you practice family planning? [ ] Yes [ ]No
Method: If no, why? ________________________________________________________
H. Method of infant feeding:
[ ] breast [ ] bottle [ ] Mixed
I. Subjects you want to learn in health education:
[ ] Drug Abuse [ ]Nutrition [ ]Family Planning [ ]Herbal Plants [ ]First Aid Measure [ ] Others: __________
Interviewed by: ______________________________
