FAMILY SURVERY FORM

No. of Families : ________________________________ Student’ Name : ________________________________

House Number : ________________________________ Course /section : ________________________________
Respondent’s Name : ________________________________ Date : ________________________________
Address : ________________________________
Age : ________________________________

I. General Information

A. Family

Members of the Family Age Sex Civil Religion Highest Residence Length of Dialect Monthly Height Weight
Status Educational Transient/ Residency Used Income (cm) (kg)
Attainment Permanent

1.

2.

3.

4.

5.

6.

7.

8.

B. Present health condition in the Family (Including AP, PP, etc.) for the past two weeks
 Member of the Onset of Illness Medical Attendance Confinement Problems Diagnosis Action Taken
Family With Without Probable Diagnosis
Symptoms if Undiagnosed

C. Death in the family during the last past 5 years (including abortion and still birth)

Name Probable Year Probable Cause Medical Attendance

With Without

II. Housing Condition and Environment Sanitation

A. House
1. House
 () Owned 8. General Cleanliness of the Surroundings
() Rented () Satisfactory
() Shared () Unsatisfactory
2. House Type 9. Kitchen
() Strong () Electric stove
() Mix () Fire wood
() Light () Gas stove
3. Materials Used () Charcoal
() Nipa () Others/specify: _______________
() Bricks
() Wood B. Source of Water
() Bamboo 1. During Dry Season
() Lawanit () Pump
() Galvanized iron () Spring
4. Presence of Accident Hazards () Nawasa
() Broken stairs () Others/specify: _______________
() Pointed sharp objects 2. During Wet Season
() Fall Hazards () Pump
() Poisons/Improperly stored medicine () Spring
() Fire hazards () Nawasa
() Obstructed entry/exit () Others/specify: _______________
() Cluttered living space 3. Distance between water source from the House/Toilet
5. Lighting Facilities () in Meters: _______________
() Electric 4. Storage of Drinking Water
() Kerosene () Jar with Faucet
() Others/specify: _______________ () Bottles
() Drums
6. Ventilation () Plastic
() Well ventilated () Others/specify: _______________
() Poorly ventilated 5. Frequently of Cleaning the Containers
() Everyday
7. General Cleanliness of the house () 3 times a week
() Satisfactory () 2 times a week
() Unsatisfactory () Others/specify: _______________

2. Methods Used in Treating Drinking Water () Boiling

() Chlorination () Others/specify: _______________
 () Closed blind
C. Waste Disposal () Open unlined
1. Toilet Facilities () Others/specify: _______________
() Owned
() Shared
2. Types of Toilet F. Vermin and Insects
() Pit privy (closed/open) 1. Types
() Pail system () flies
() Antiseptic () rats
() Water sealed () mosquitoes
() Others/specify: _______________
() cockroach
() others/
3. Distance of the Toilet from the House in meters specify______________________
________________________________ 2. methods used in Eliminating
4. General Cleanliness
() fogging
() Satisfactory () killing
() Unsatisfactory () screening
() trapping
D. Garbage Disposal () poisoning
1. Method of Disposing () request for help
() Hog feeding () none
() In a pit ()
() In the river others/specify_______________________
() Open dumping
() Open burning
() Others/specify: _______________
G. Pet Animal
() dog
E. Drainage System () cat
1. Type ()
() Open stagnant canal others/specify_____________________
 H. Background Gardenning 3. List of foods given to children aside from
() Fruit bearing breast milk
() herbal () am
() vegetables () porridge
() others/ () Milk formula
specify_____________________ () eggs
() potatoes
() others/
specify____________________
4. At what age are these foods given?
III. Nutrition __________________________
1. Approximate weekly budget for food______________ _______
2. Food usually bought, prepared and 5. List of foods usually given to children for
eaten________________________________________ snacks
3. General Impression of Nutrition Status () bread
(
1. List of food items that the pregnant women a. Infant ) Fairly Well
usually eats nourished nourished
() fish b. Pre-schoolersb
c. schoolers
() eggs o
d. adults
() vegetables i
() meats led banana
() fruits () fruits
() others/ () junks
specify__________________ ()
2. List of food items given to the baby after others/specify_______________
birth aside from breast milk
() boiled water with sugar IV. Pre-natal and Post –Natal Care
() ampalaya juice 1. Presently
() honey pregnant__________________________
() others/ specify Last menstrual
period_______________________
 Age of () yes
pregnancy__________________________ () none
Expected date of 8. Vaccination the baby has;
delivery____________________ () BCG
2. Did she have pre-natal supervision?, If yes, () Hepa B
to whom and where? () DPT
() yes () OPV
__________________________ () others
_____ specify____________________
() no ___
3. Anyone who have just delivered? 9. Other children
() yes 1. Type of immunization
() none received______________________
4. Gender of the baby __________
() male 2. Reason for not being
() female immunized____________________
5. Where was the baby delivered? __________
() at home
() at the lying in V. Family Planning
() at the hospital 1. Desired number of children
() others/ () 2
specify___________________ () 3
6. Who attended the delivery? () 4
() doctor ()
() midwife others/specify_________________________
() others/ 2. Methods preferred for fertility regulation
specify__________________ () withdrawal
() IUD
7. Did the baby has a well baby check up?, if () pills
yes to whom and () rhythm
where?______________________________ () jellies
______ () abstinence
 () condoms () when there is a pregnant who is about
() implant to deliver
() ligation () when a child is needed to be
() others/ specify__________________ immunized
3. Heard about family planning? If yes to () other/specify
whom? __________________________
() yes 3. First person to be consulted in times of illness
_____________________________________ () rural health doctor
() no () spiritista
4. Method presently using? How long? () herbolaryo
____________________________ () private doctor
() nurse
() midwife
() other/ specify __________________
VI. GENERAL HEALTH BELIEFS AND PRACTICES 4. Was there a family member who needed
1. Understanding of the common caused of medical help but
illness of the did not sought consultation ?
people in the community. () yes
() poor personal hygiene () no
() evil spirit 5. If yes, what was the reason?
() night air () could not afford
() inadequate rest () no ride available
() inadequate food () against religious beliefs
() poor environmental sanitation () patient refused
() contact with person with () no idea where to bring the sick
communicable diseases () other/specify
() other/ specify
_________________________ 6. Did you consulted a dentist? If yes, when?
2. When is hospital or health center used? () yes, ___________________________
() only if there is sick member of the () no
family
7. If no, are a the reasons for not consulting?
 () financial restraints 13. Number of hours of nap per day
() afraid of the dentist () 2 hours
() others/ () 1 hour
specify____________________ () 30 mins.
8. Is there anyone in need of dental service right () other/ specify
now?
() yes 14. How many glasses of water taken everyday ?
() no () 8 glasses
9. What is being used to clean the teeth? () 10 glasses
() tooth brush with toothpaste () 6 glasses
() tooth brush with salt () other/ specify
() guava twig 15. Other fluids intake
() other/ Specify () coffee
______________________ () tea
() juice
10. When is washing of hand is necessary? () other/ specify
() before and after eating
() after using toilet
() after touching dirty things VII. RECREATION
() other/
specify_____________________________ 1. Recreation activities present in the community
11. Use for handwashing () play ground
() plain water () cockpit
() water and soap () gambling
() hand sanitizer () games
() other/ specify Outdoor________
___________________________ Indoor__________
12. Number of hours of sleep every night () others/
() 4 hours specify________________________
() 8 hour 2. What are the leisure activities of the family
() 2 hours when resting?
() other/specify () drinking spree
 () play cards () Brgy. Captain
() watching TV () Brgy. Council
() listening to radio () people
() Face book () other/ specify____________________
() other/
specify__________________________ 3.Common problems on waste disposal
3. Is there any member of the family who () not collected on time
smoke? If yes, () dispose anywhere
number of packs/sticks per () no dump site
day._________________ 4.Common diseases in the community
4. Type () cough and colds
() tobacco () Dengue Fever
() vape () Tuberculosis
() cigar () diarrhea
() other/ ()
specify______________________ other/specify_________________
5. Is there any member of the family drink 5.How many are unemployed in the family
alcoholic __________________________
beverages? If yes, what
type________________
() yes
() no

VIII. COMMON PROBLEM IN THE COMMUNITY

1. If somebody is ill, who is the first person to be approached?
() Brgy. Captain
() Brgy. Council
() midwife
() nurse
() family
2.who makes the decision for any project/activities in the brgy.?