OLLEGE OF NURSING

1st Semester SY 2023 - 2024

CLINICAL AFFILIATION PROGRAM

COMMUNITY HEALTH NURSING 2 (NCM113)

Community Initial Data Base

Name:
Age:
Address:

A.
1. Most common reason to visit your Health Center.

□ Colds □ Check – up
□ Cough □ Medicine consultation
□ Fever □ Monthly check up
□ Immunization
2. Where did you and your family go to consult when someone in the family is feeling
ill?

□ Health Center □ Faith Healer

□ Doctor □ Ob - GYNE
3. What type of medication do you use?

□ Medicine from the Doctor □ Medicine from Faith healer

□ Medicine from the Health
Center
4. Do you have Health workers that regularly visit and available in Barangay?

□ Yes □ No
 5. Most common cause of illness?

□ Sanitation □ Contaminated food and water

□ Not enough knowledge about □ Climate change
nutrition
6. What method of family planning is being used?

□ LAM □ DMPA
□ Ovulation □ IUD
□ Symptothermal □ Tubal Ligation
□ Pills □ Vasectomy
□ Condom
B. Socio – Economic and Cultural Variable
1. House materials

□ Wood □ Wood and concrete

□ Concrete □ Bamboo and nipa palm
2. Church or Chapel?

□ Available □ None
3. Hospital?

□ Accessible □ None
4. Health Center?

□ Accessible □ None
5. Source of Light?

□ Electricity
□ Lamp
□ Lantern
 □ Others
6. Types of Communication with in the community?

□ Cellphone □ Announcement
□ Telephone □ Other
□ Poster

7. Types of Transportation?

□ Jeepney □ Bicycle
□ Car □ Others

□ Tricycle
8. School

□ Elementary
□ Secondary/High school
□ College
□ Kindergarten
Environmental Indicators

A. Location of House

□ Plains
□ Mountain
□ Sea side
B. Type of House

□ Concrete
 □ Not Concrete
C. Water supply

□ Well □ Water work system

□ Private □ Water pump
□ Lake □ Others
D. Water

□ Tank □ Others
□ Drum
□ Container
E. Bathroom

□ Water sealed
□ Buhos
□ Antipolo
□ Others
F. Types of drainage

□ Open drainage
□ Close drainage
G. Garbage disposal

□ Segregragation
□ Compost
□ Garbage collection
□ Others
 H. Factory in your community?

□ Yes
□ No
Health and Illness

I. What is the leading causes of mortality in your community?

II. What is the leading causes of morbidity in your community?
III. What is the leading causes of infant and child mortality in your community?
IV. What is the leading causes of hospital admission with in your community?
V. What is the leading causes of clinic consultation with in your community?
VI. What is the Nutritional Status of the Community?

Form #01- CHN 2 JJG