Far Eastern University

Institute of Nursing
Community Health Nursing

Community Health Survey Tool

Head of the family:_Janet Faeldan

(sino ang kinikilalang puno ng pamilya?) Primary dialect spoken: Tagalog at Odionganon
Complete address:_Victor Manayon St. Brgy. Uyao, Roxas, Oriental Mindoro (pangunahing dialektong ginagamit sa bahay)
(Tirahan: house #, street, barangay)
Length of residency: Permanent Control number:________________________________________
(tagal ng paninirahan ng pamilya sa lugar)
Surveyed by: Kristina Cassandra Carido
o Transient (less than 6 mos)
(complete name of student)
o Permanent (6 mon and longer)
Place of origin: Luzon Date: November 21, 2023
(date of completion)
(Lugar na pinagmulan ng pamilya)
O Luzon O Visayas O Mindanao Family structure □: __nuclear __extended __dyad __compound
__others, specify: ______________________
Ethnic background: ____________________________
(pangkat etnikong kinabibilangan ng pamilya)

I. Demographic Table
Education Employment Other Total
Highest source monthly
Relationship Age as educationa Educationa Occupation of income of
to the head of Date of of the Civil l l status for status for income each earning
attainment ages 15-64 ages 15-64 Type (iba pang
Name of family member(s) the family Gender birth last status Religion member
(pinakamata y/o) y/o (uri ng pinagkuk
No (buong pangalan ng (kaugnayan (kasaria (buwan, birthday (estad (relihiyon) as na antas (estado ng (estado ng trabaho) (buwanang
miyembro ng pamilya sap uno ng n) petsa at (edad o unan ng kita ng bawat
ng edukasyon trabaho kita ng
pamilya) taon ng ayon sa sibyl) edukasyon para sa 7- para sa bawat
miyembrong
kapanga huling natapos) 20 y/o edad15- miyembro may trabaho)
nakan) kaarawan 64y/o) )
)
1 Christopher R. Faeldan Spouse M January 48 M C HG E Farmer 5,000-8,000
12, 1975
2 Janet Joy F. Faeldan Head F August 3, 48 M C CG E Clinical 100,000
1975 Nurse
3 Patricia Anne F. Faeldan Daughter F February 21 S C CU PS X
25, 2002
4
5
6
7
o Within poverty threshold (2000 per family member per month or greater ; at least P10,000/ month for 5 members*) Total Family Monthly Income: P 105,000
o Below poverty threshold (less than 2000 per family member per month; less than P10,000/ month for 5 members)
Legend : M – male C – Child (14 y/o & LS – Leggaly Separated X – none CU – college undergrad E- employed
F- female below) C – Catholic GS – graduate studies UE – under
S – Single (15 y/o & P – Protestant EG – elem. grad. None – over 7 y/o has Employed
above) SA– 7th day Adventist EU – elem. undergrad not gone to school. X- unem-
M – Married INC– Inglesia ni Cristo HG – highschool grad PS – presently studying Ployed
CL – Common law J – Jehova’s Witness HU – highschool undergrad OSY – stopped studying
W – Widowed I – Islam CG – college grad NFE – no formal educ
II. Socio-economic and Cultural Variable Formal channels
1. Land and/ or house ownership: o general assembly
(sino ang nagmamay-ari ng inyong tirahan?) o bulletin boards, memorandum and written announcements
o owned land and house o home visit through the BHWs
o owned land OR house o others, please specify: ___________
o rented
o rent-free Informal Channels
o rent-to-own o gossips
2. (Observe type of construction materials) o others, please specify: ___________
o light
o strong 7. Transportation system used to access health care facilities
o mixed (health center, clinics, nearest hospital)
(Paano kayo nakakapunta sa health facilities, health centers, clinics at ospital?)
3. Number of rooms used for sleeping: _3__ o private vehicle
(ilan ang kwarto o lugar na ginagamit bilang silid-tulugan?) o jeepney
o tricycle
O1 O4 O7 O10 o bus
O2 O5 O8 O more than 10 o barangay service/ shuttle
O3 O6 O9 o others: specify_______
8. What is your perception of a healthy person?
(Ano ang pananaw nyo sa isang malusog na tao?)
4. Prioritization of expenditures: o Physically healthy
(Ano ang pangunahing prayoridad sa gastusin? Lagyan ng bilang ayon sa - mataba, matangkad, mapula ang pisngi, makinis ang
pagkakasunod sunod ng prayoridad sa gastusin)
balat
o Mentally healthy
_1__food
- nag-iisip ng matuwid, matino ang utak, matalino
_6__ shelter/ housing
o Emotional healthy
_5__ clothing
- masayahin, palangiti, hindi iyakin, tugma sa pangyayari
_3__ education
o Spiritually health
_2__ utilities (water, electricity, internet, cable)
- madasalin, may takot sa Diyos, nagsisimba
_4__ health savings/ healthcare
o Absence of disease/ infirmity
___ others, specify____________
- walang sakit, hindi sakitin
9. In your perception, what causes disease?
5. Resources allotted for healthcare
(sa inyong pananaw, ano ang pangunahing dahilan ng pagkakasakit at
(saan galing ang inyong ponding pangkalusugan?) kapansanan?)
o Yes: if yes, where does it come from? o Biological:
o SSS - Virus, bacteria/ microbes, fungus, parasite
o GSIS o Chemical:
o PhilHealth - Insecticide, nicotine, lead, mercury
o HMO, Health Insurance/ Medicard o Physical:
o Others:_____ - changes in weather, humidity, radiation
o None o Mechanical:
6. Communication network necessary for disseminating health - Stab, trauma
information or facilitate referral o Nutritive:
(Paano nakakarating sa inyo ang balitang pangkalusugan o ang mga - Iron deficiency, insufficient intake, cholesterol
anunsyo ng barangay? Check all that applies) o Others, specify:___________
10. First personconsulted in times of illness:
(sino ang unang una nyong pinupuntahan kapag ang isa sa pamilya ay may
sakit?)
o Healthcare Professionals and allies:
- doctor, nurse, midwife, dentist, BHW/Councilor for
Health
o Non-professionals:
- “hilot”, “albularyo”, elders, non-healthcare related people
or professionals
o None

11. Medications taken during illness:

(Sino and nagbigay o nagpayo ng gamot na inyong iniinom tuwing may sakit?)
o Prescribed by doctor
o Self medication: advised by people other than the doctor: nurse,
midwife, elders, relatives, friends, or by self (over the counter)

III. Environmental indicators

o Daily
12. Source of Water supply: o Every other day
(saan nanggagaling ang tubig na ginagamit nyo sa inyong bahay?) o Twice a week
o Level I (point source: well or a developed spring with an outlet but o Once a week
without a distribution system, generally adapted for rural areas o Once every 2 weeks
where the houses are thinly scattered; normally serves an average o Monthly, or even longer
of 15 households; farthest household not more than 250 meters)
o Level II (communal faucet system or standposts: system composed 15. Types of garbage disposal system (check specific type):
of a source, a reservoir, a piped distribution network, and communal (Ano po ang paraan ng pagtatapon nyo ng basura?)
faucets; serves 4 to 6 households; should not be located more than o Acceptable methods:
25 meters from the farthest house) ____ Garbage Collection
o Level III (waterworks system or individual house connection: ____ Composting
system with a source, a reservoir, a piped distribution network and ____ Recycling/ Reusing
household taps; generally suited for densely populated urban o Not acceptable methods:
areas) ____ Hog feeding
____ Open dumping
13. Sanitation method of drinking water: ____ Open burning
(Ano ang paraang ginagamit ninyo upang mapanatiling malinis ang inuming ____ Burial pit
tubig?) ____ Others: ______________
o Boiling 16. Types of excreta disposal system (check specific type):
o Sedimentation (ano pong uri ng palikuran mayroon kayo? Paano itinatapon ang mga dumi o
o Filtration ihi?)
o Others, specify_Distilled Water___ o Acceptable and safe:
____ Pour-flush type latrine or “ de buhos” (with water supply)
14. % Population served by daily garbage collection system: ____ Flush-type (with water supply)
(Gaano kadalas kinokolekta ang basura dito sa inyo ng trak?) ____Water-sealed latrine (with water supply)
____ Antipolo type (if with water supply, and within standards)
 o Unsanitary and unsafe:
_____ Overhung latrine 19. Death in the family from October 24, 2015 to October 24, 2016
_____ Bored-hole latrine (Mortality):
_____ Open pit privy (Sino po sa pamilya ang sumakabilang buhay mula Oktubre 24 2015
_____ Pail system hanggang Oktubre 24 2016?)
17. Drainage system:
(Ano po ang uri at kondisyon ng kanal mapalit sa inyong bahay ?) What is the underlying cause of death
o Open drainage and flowing Age on according to the death certificate? (Ano ang
o Open drainage and stagnant Name death / pangunahing sanhi ng pagkamatay ayon sa
Gender
o Blind drainage sertipiko ng kamatayan?)
o No drainage, waste water flows indefinitely anywhere

IV. Health and Illness Patterns

18. Incidence of illness in the family from October 24 2015 –
October 24 2016 (Morbidity):
(Sino po sa pamilya ang nagkaroon ng sakit mula Oktubre 24 2015
hanggang Oktubre 25 2016?)
20. Nutritional status of children 0-6 years old (Geth the height and
weight of all children 0-6 y/o and classify nutrition status according
to the Filipino Children weight per height table from the Nutrition
Program of DOH)
(Maari ko po bang sukatin ang timbang ng mga batang 0-6 y/o?)

If not Interventions (Ang

If diagnosed by a diagnosed, maysakit ba ay Name of Age in Height Weight Underweight✅ Normal Overweig
Age/ doctor, what is the what are the nagamot o hindi children month in cm in kg. Mild Mod. Sev. weight ht
Name Gender diagnosis? (Ano ang signs and nagamot) 0-6 y/o s/
sakit ayon sa doctor?) symptoms? Treated Untreated Gende
(Ano ang mga r
✅ ✅
sintomas at
senyales?)
 21. Risk Factor Assessment for malnutrition of children 0-6 years 22. Health Center Programs, awareness and utilization: (Anu anong
old: (Ang mga sumusunod po ay salik sa pagkakaroon ng problema sa programa sa health center ang iyong alam? Anu anong programa sa
nutrisyon ng mga batang 0-6 y/o. Alin po sa mga sumusunod ang health center naman ang ginagamit at pinakikinabangan ng pamilya?
nararanasa ng anak at pamilya sa kasalukuyan?) Banggitin lahat.)
Aware but Not aware,
not utilized Aware and does not
(Alam Utilized realize
subalit hindi (Alam at (Hindi alam,
Health Programs Ginagamit) hindi
Family Oral Iodized Low For children Regular ginagamit)
ginagamit)
food Vitamin: Salt Birth 6 months & intake of ✅
threshold A Utilization Weight below protein- ✅ ✅
below supplem (Gumaga (noong Exclusive rich,
1. Adolescent and Youth Health and ✓
P8000/mo ent mit ba isinilan Breastfeedi carbohydra
Development program
*? (Ang within 6 kayo ng g ba ng? tes and
2.Botika ng Barangay ✓
perang months iodized ang (nagpapasu essential
Age/Gen inilalaan (Napatak salt sa bata, so ba kyo micronutrie 3.Breastfeeding Program ✓
Nam der sa an ba ng pagluluto kulang ng nts from 4.Childhealth ✓
e of pagkain Vitamin ng ba siya eksklusibo vegtables 5.Diabetes Mellitus Prevention Program ✓
child ng A sa pagkain sa walang and fruits 6.Dengue Control Program ✓
0-6 pamilya bibig sa ng mga timban halong (Araw- 7.Dental Health Program ✓
ay mas loob bata sa g?) tubig o araw ba 8.Doctors to the Barrios (Medical Consultation) ✓
mababa nitong 6 bahay?) ibang siyang 9.Environmental Health ✓
pa sa na ✅ if gatas?) kumakain 10.Expanded Program on Immunization ✓
P8000 buwan?) ✅ if YES YES ng gulay, 11.Family Planning ✓
kada ✅ if NO prutas, 12.Food Fortification Program ✓
buwan?) ✅ if isda o 13.FOURmula One ✓
NONE karne at 14.Garantisadong Pambata ✓
✅ if YES itlog, o 15.Health Lifestyle Program ✓
umiinom 16.Knock-Out TIgdas ✓
ng gatas?) 17.Ligtas Tigdas ✓
18.National Cardiovascular Disease Prevention ✓
✅ if NO and Control Program
19.TB Control Program ✓
20.Natural Family Planning ✓
21.Nutrition Program ✓
yes no 22.Person with Disabilities Program ✓
23.Pnuemonia and Acute Respiratory Infections ✓
Program
24.Prevention of Blindness Program ✓
25. Rabies Control Program ✓
26.Safe Motherhood and Women’s Health ✓
Program
27.Smoking Cessation Program ✓
28.Soil Transmitted Helminthiasis program ✓
 23. Maternal and Child Care:
(For Pregnant woman/women in the family) 26. Immunization status of children 0-12 months of age:
Name OB score AOG in EDC(LM Prenatal Check up: Tetanus Toxoid (Anu-ano na po ang mga bakunang natanggap ng mga batang edad
of GPTPAL weeks P-3 atleast 1 for 1st Immunization 0-12 months?)
Pregna M (count months trimester, atleast 2 if
Category:
nt from day plus 7 on 2nd trimester, at
woman 1 of last days) least 3 if on 3rd
menstru trimester, at least 4

Specifics age in months/ gender

al if approaching EDC
period)

Anti Measles Vaccine

With WIthout With Without/inc

NO IMMUNIZATION
FULLY IMMUNIZED
✅ ✅ ✅ ✅

Name of Child

INCOMPLETE
COMPLEYE
Hepa-B 1

Hepa-B 2

Hepa-B3

DPT31

OPV 1

OPV 2
DPT 1

DPT 2

OPV3
BCG
24. Risk Factor Assessment for High Risk Pregnancy: (For
Pregnant woman/women in the family)
Put a ✅ on all that applies:

With pre-existing illness: heart

Smoking? Alcoholic? Taking

Age Below 18 & 34 above?

gestational-age baby, large

Weight of below 100lbs or

miscarriage, preterm labor

STD, and other infection?

autoimmune disease, TB,
and/or delivery, small-for-

disease, AIDS, asthma,

cancer, kidney disease,

Smoking? Secondhand
With Thyroid Problem?
baby, pre-eclampsia or

More than 3 previous

Previous stillbirth,
Height under 5ft?

Hypertensive?

Pregnancies?

illegal Drugs?
V. Political/Leadership Pattern/ Action Potential
eclampsia
OB Score

Diabetic?
obese?
Name

27. Recognition of Authority:

Age

(Sino ang unang una ninyong nilalapitan upang hingan ng tulong sa

barangay kapag may problema?)
o Barangay Chairman
o Kagawad for Health
o Kagawad for Peace and Order
o Kagawad for Infrastructure
Immu o Kagawad for Livelihood/ Ways and Means
25. Utilization of Family Planning Methods: o Kagawad for Environmental Sanitation
(Applicable to married or common law women ages 15-44 y/o, and o other council members, specify name: ______________
married or common law men of all ages; answers should be per
o barangay tanod, specify name: ____________________
individual)
(Kayo po ba ay gumagamit ng family planning methods? Ano po ang ingong ginagamit o Barangay health worker, specify: ______________________
na pamamaraan?) o Health Center Personnel, specifically: __________________
Put a ✅ on all that applies: o other people, specifically: ___________________________
For Acceptors Only Specify
Non- the
Name Age/Gender Acceptor Natural Artificial Permanent
acceptor Method
Method Method Method
Used:
 28. Utilization of barangay programs and services:
(Alin sa mga programa o serbisyo ng barangay chairman at council ang
inyong alam at pinakikinabangan o sinasalihan?)
Barangay Programs and Aware but does Aware, utilize, and Not aware, does
Projects not utilize or participate not utilize or
participate participate
Livelihood Program ✓
Clean and Green/ Sanitation ✓
Program
Liga/ Sports-oriented projects ✓
Medical Missions ✓
Others: specify

29. Conditions/ issucs/ events that cause social conflicts/

upheavals:
(Anong kundison, pangyayari, o isyu ang nagaganap sa barangay na
madalas nagdudulot ng di pagkakasunduan, pag-aaklas o gulo? Magbigay
ng isa.)
Away sa lupa at nakawan ng mga produkto

30. Conditions that lead to social bonding/ unification:

(Anong pangyayari naman ang madalas na nakatutulong upang magkaisa o
magbuklod ang barangay? Magbigay ng isa.)
Kapistahan o clean-up drive

31. Practices/ approaches effective in settling issues and concerns

within the community:
(Para sa inyo, ano ang pinakaepektibong pamamaraan na ginagamit ng
barangay upang tugunan ang mga problema ng residente o di kaya'y ayusin
ang mga alitan?)
o conciliation settled by Lupong Tagapayapa headed by the Chairman
o settled by the Philippine National Police assigned to the area
o other means, specify: ________________________________

32. Perceived problems in the community:

Sa inyong pananaw, an ang pangunahing problema ny inyong barangay na
dapat bigyang solusyon, sa lalong madaling panahon?
Improper Waste Management

33. Perceived solutions:

Sa invong pananaw, an ang pangunahing solusyon para sa inyong nakitang
problema?
Proper segregation of wastes