CALOOCAN HEALTH DEPARTMENT

Camarin Health Team

Community Health Survey Tool

Who is the head of the family? __________________________________ Control No. # _____________

(Sino ang kinikilalang ama ng pamilya?) Surveyed by: ______________________
What is your complete address? _________________________________ (Pangalan ng nag – survey)
(Ano ang inyong kumpletong address?) Date: ________
For how many months/years have you been residing in your house? __________
(Ilang buwan/taon na kayo naninirahan sa inyong tahanan?)
 Permanent (more than 6 months of stay)  Transient (6 months and less)
Where is the place of origin of the head of the family? (ex. Pampanga, Bicol, Cebu etc.) ______________
Check if found in:
 Luzon  Visayas  Mindanao

Family Structure, Characteristics and Dynamics

No. What are the names of the What is the relationship Check one of the boxes what What is the What is the date of birth of What is the age of each What is the civil status What is the religion of
(Blg) household member? (Anu – ano of each member to the type of family according to gender of each each member of the member as of the last of each member of the each member of the
ang pangalan ng mga miyembro head of the family? (Ano structure do they have member of the family? (Ano ang petsa ng birthday? (Ano ang mga edad family? (Ano ang family? (Anong
ng pamilya?) ang kaugnayan ng (Lagyan ng tsek ang isa sa family? (Ano ang kanilang kapanganakan ng ng bawat miyembro ng estado sibil ng bawat relihiyon ng bawat
bawat miyembro sa mga kahon kung anong uri ng kasarian ng bawat bawat miyembro ng pamilya ayon sa huling nilang miyembro ng pamilya?) miyembro ng pamilya?)
kinikilalang pinuno ng pamilya meron sila) miyambro ng pamilya?) kaarawan?)
pamilya ?) pamilya?)
HEAD
 Nuclear
 Extended
Single parent
 Communal
 Blended
 Compound
 Gay- Lesbian Rel.
 No kin
 Foster
 Dyad
 Live-in

LEGEND:
HEAD – Head of the Family M – Male S – Single C - Catholic
F – Female M – Married P – Protestant
W – Widowed SA - Adventist
LS - Legally Separated INC – Iglesia ni Cristo
CL – Common Law JW – Jehovah’s Witness
I – Islam
B – Born Again
A – Aglipayan
EL – El Shaddai
What is the highest educational
attainment of each member of
the family? (Ano ang
pinakamataas na antas ng
edukasyon ang natapos ng
bawat miyembro ng pamilya?)
What is the educational status of
each member of the family?
(Anong estado ng edukasyon ng
bawat miyembro ng pamilya?)
Where does each member of the
family works? (Saan
nagtratrabaho ang bawat
miyembro ng pamilya?)
What is the occupation of each
working family member? (Ano
ang trabaho ng mga
naghahanap buhay ng bawat
miyembro ng pamilya?)
What is the occupational status
of the household members?
(Ano ang kalagayan ng trabaho
ng bawat miyembro ng pamilya?)
What is the degree of the
occupation/work of each of the
family members? (Ano ang antas
ng trabaho ng bawat miyembro
ng pamilya?)
How much is the net salary of
each working family member per
month? ( Magkano ang naiiuwi
ng bawat miyembro ng pamilya
na may trabaho sa isang
buwan?)
LEGEND:
EG – Elementary Graduate NF – No Formal Education WB – Within Barangay P – Permanent E - Employed
EU – Elementaryh Undergrad. PS – Presently Studying OBW – Outside Barangay C – Contractual UD - Underemployed
HG – HighSchool Graduate SS – Stopped Studying w/in Batangas UE - Unemployed
HU – HighSchool Unergrad. OB – Outside Batangas
CG – College Graduate
CU – College Undergrad.
V – Vocational
M – Master’s Degee Holder
PhD–Doctoral Degree Holder

COMMUNITY AS A SOCIAL SYSTEM

A.Economic Aspect

16. Do you have other resources of income? (Mayroon po pa bang ibang pinagkukuhanan ng kabuhayan?) __ Food(Pagkain) Php ________ __Health(Kalusugan) Php ________ __ Water bill (Bayarin sa tubig) Php ________
 Yes  No __ House rental (Upa sa bahay) Php ________ __ Education (Edukasyon) Php ________ __ Clothing (Damit) Php _____
If Yes, What? (Kung mayroon ano po ang mga ito?) __ Leisure (Panlibangan) Php _________ __ Electric bill (Bayarin sa kuryente) Php ________ Others: ____________
 Sari – sari store  Poultry raising  Others, please specify _______________
 Craft making  Livestock raising 20. What are the resources allotted for health care of the family? (Anu-ano ang nakaalaang pondo para sa kalusugan ng pamilya?)
 Yes  No
17. What is your combined monthly family income? (Magkano ang kabuuang buwanang kita ng pamilya?) If Yes, from where? (kung oo, galling saan?)
_________________________  Health Insurance  SSS/GSIS  Phil Health  Bank savings  Others __________
POVERTY TRESHOLD DETERMINANT:
Php 1,239 x NO. OF FAMILY MEMBERS = _______________
If the combined family income is less than the poverty threshold the the family is in state of poverty
 Enough  Not enough/ State of Poverty

18. What is your total monthly family expenditure? (Magkano po ang kabuuang gastos ng inyong pamilya?)
________________________

19. Priority Expenditure, rank it 1-8 (1 is the highest; 8 is the lowest)

How much do they spend in each category? (Magkano ang ginagastos sa bawat kategorya?)

31. What lighting facilities are you using in the house? Is it adequate or not?
C. Environmental Aspect (Ano po ang ginagamit niyong ilaw sa bahay? Sapat po ba ito o hindi?)
 Incandescent Lamp (Light bulb)  Flourescent Lamp  Candle
30. What is your perception regarding your ventilation, is it adequate or not?  Kerosene Rechargeable lamp
(Ano po ang inyong masasabi tungkol sa bentilasyon o pasukan ng hangin, sapat po ba ito o hindi?) Is it  Adequate or  Inadequate
 Adequate  Inadequate 32. What is the type of latrine you used in your house?
(Anong uri ang giangamit ninyong palikuran sa inyong bahay?
 __ water tank
TYPE 1 TYPE 2 TYPE 3
 Pail system  Antipolo type  Flush type 40. What method do you commonly use in sanitizing water?
Open pit privy  Water-sealed latrine (Anong paraan ang karaniwang ginagawa sa paglilinis ng tubig
 Overhung latrine na iniinom?)
 Bored Hole latrine  Boiling water (pagpapakulo) - How many minutes? __________
 Close pit privy  Filtration (pagsasala) (Ilang minuto?)
 Sedimentation (pagpapalatak)
33. Do you own this toilet facility? (Pagmamayari niyo po ba ang palikuran sa inyong bahay?)  None – For what reason? _____________________
 Private (Sariling pagmamayari) (Sa anong kadahilanan?)
 Shared (2 families)
 Communal (3 or more) 41. Do you have dogs or cats?
(Mayroon po ba kayong alagang aso’t pusa?)
34. What is the sewerage system in your community? VACCINATION
(Ano ang uri ng kanal sa inyong komunidad?) KIND NO. FOR EACH ANIMAL (Bakuna sa Hayop)
 Blind drainage (URI) (BLG.) NAKAKAWALA NAKAKULONG WITH WITHOUT
 Open drainage (Mayroon) (Wala)
 None

35. What is the condition of the flow of water in the creek in your community?
(Ano po ang kalagayan ng daloy ng tubig sa kanal ng inyong barangay?
 Free flowing  Stagnant
42. Are there any present vectors and rodents in the house?
36. What is the type of waste disposal used in your community? (mayroon bang peste sa loob ng bahay?)
(Anong pamamaraan ng pagtatapon ng basura ang ginagamit sa inyong barangay?)
WAYS ACCEPTOR NON ACCEPTOR HOW OFTEN VECTORS WITH WITHOUT WAYS OF BREEDING SITES
HOG FEEDING (PESTE) (MAYROON) (WALA) REDUCING (PINAMAMAHAYAN)
OPEN DUMPING (PARAAN NG WITH WITHOUT
PAGPUKSA) (MAYROON) (WALA)
OPEN BURNING
BURIAL PIT  Flies  Flytraps
(Langaw)  Insectides
COMPOSTING
 Screens
GARBAGE COLLECTION   Insecticides
OTHERS Cockroaches  Screens
(Ipis)  Flytraps
37. What are the containers used for dumping garbages? ( Ano ang ginagamit na tapunan ng basura sa inyong
 Chalk
komunidad?)
 Rat (daga)  Mouse traps
 Garbage bag
 Screens
 Waste basket
 Pellets
 Sack
 Bed bugs  Insectides
 None
 Moth balls
Do you practice waste segregation? __________
 Screens
If no, what would be the reason? _____________________________
 Mosquitoes  Insectides
 Repellant
 Screens
38. Where is the main source of drinking water? (Saan nanggagaling ang iniinom na tubig?)
D. Health Aspect
LEVEL 1 LEVEL 2 LEVEL 3 COMMERCIALLY PREPARED
 Artesian Well  Deep well  Local  distilled 43, What are the foods you and your family usually eat in 1 week?
 Streams Water  purified (Ano ang kadalasan kinakain ng inyong pamilya sa loob ng isang lingo?)
 River System
ACCEPTED
 Springs
Fats, Oils and Sugar Animal foods, dried Vegetables and Rice and other cereals
beans and nuts fruits and bread and rootcrops
39. Where do you store your drinking water? (Saan iniimbak ang inyong inumin tubig?)
STORAGE COVERED UNCOVERED
__ Jar (banga)
__ Bottles (bote) NOT ACCEPTED
__ plastic/ glass container  Junkfoods  Softdrinks  Bagoong  Patis
__ water dispenser
44. Where do you store your food?
 (Saan iniimbak ang inyong pagkain?) 49. Immunization Status of Target Age Group (8 years old and below)
STORAGE COVERED UNCOVERED
What is the What is What are the immunizations Remarks
 Refrigerator name of the the age in receive by the member of the
 Table family months of family? Check among the
 Basket member? the family choices.
Ano ang member? Ano ang mga bakunang
45. Do you take your medicines during illness? pangalan ng Ano ang natanggap ng miyembro ng
 Yes  No miyembro ng edad sa pamilya? Lagyan ng tsek sa
If yes,  Prescribed  Not prescribed pamilya? buwan mga sumusunod
ng
46. (For female ages 15-45, and for male ages 15 and above) miyembr DPT OPV Hepa-B Incomplete Fully None
What are the methods used in family planning o ng Immu\nized
Anu-ano ang mga paraang ginagamit sa pagpplano ng pamilya? pamilya? 1 2 3 1 2 3 1 2 3
What is the name of the What is the age Do they If yes, please specify the methods used according
family member? of the family practice any to the categories.
Ano ang pangalan ng member as of family planning Kung oo,anong pamamaraan ang ginagamit base
miyembro ng pamilya? his/her last methods? sa mga kategorya
birthday? Gumagamit ba
Ano ang edad sila ng paraan 50. Nutritional Status for Children (0-83 months or 0-7 years old)
ng miyembro ng sa pagpaplano
pamilya ayon sa ng pamilya? What is What is When was the What is the date What is the What is the What is Remarks
the name his/her date of weighing of birth of the age in weight? the Underweight Normal Overweight
kanyang huling Yes No Natural Artificial Permanent of the gender? of the family family member? months of Ano ang height? Weight
kaarawan? Contraceptives family Ano ang member? Ano ang petsa ng the family kanyang Ano ang
 Rhythm  Condom  Vasectomy member? kanyan Kailan ang petsa kapanganakan ng member? timbang? sukat ng
Ano ang g ng pagtimbang miyembro ng Ano ang taas?
 Basal Body  IUD  Ligation pangalan kasaria ng miyembro ng pamilya? edad sa
Temperature ng n? pamilya? buwan ng
 STH  Pills miyembro miyembro
 LAM ng ng
pamilya? pamilya?
 Cervical
Mucus Method

For items 47 -50: Answer only if applicable

*_____________-If there are children 0-12 months in the family
*_____________-If there is a pregnant member of the family
*_____________-If there are children 0-83 months (o-7 years old) in the family

47. What kind of milk does the newborn baby intake?

Anong klaseng gatas ang iniinom ng mga bagong panganak na bata?
( )Breastmilk(Pure) ( )Formula
( )Breastmilk with water ( )Breastmilk and Formula
If breastmilk, for how long does the baby take this milk?
Kung nagpapaded, gaano katagal na ito iniinom ng bata?
______________________________________

48. Maternal Care

What is the name of How many When was the What is the When’s the Did you receive
51. MORBIDITY (from December 2007-2008)
the pregnant mother times have first day of your age of your expected date tetanus toxoid
Anong pangalan ng you been last menstrual gestation? of delivery? examination?
nagbubuntis na ina? pregnant? period? Ilan buwan Kailan po Nakatanggap na ba
Ilang beses Kailan ang na kayong inaasahang kayo ng tetanus
na kayong unang araw ng nagbubuntis? petsa ng toxoid
nagbuntis? inyong huling inyong examination?
buwanang kapanganakan
dalaw? ? With Without
 What is the What is the What When did What are the Did he/she consult a What is the Is there any What is
name of the age of the is his/ it start? signs and physician? Diagnosis? interventions done? the kind
family family member her symptoms? of
member? as of his/her gender Kailan ito Kumonsulta ba siya sa Ano ang Mayroon bang mga interventi
last birthday? ? nagsimul Ano ang mga dockor? mga paraang ginawa upang on?
Ano ang a? simtomas? posibleng malunasan ito?
pangalan ng Ano ang edad Ano problema na Ano ang
miyembro ng ng miyembro ang With Without nakita? With Without klase ng
pamilya? ng pamilya kanyan Physician Physician inter- panggaga
ayon sa g Consultant inter- mot?
kanyang kasaria Consultant vention
huling n? vention
kaarawan?

52. Mortality (from December 2007-2008)

What is the How old What is When What is the cause of death
name of the is his/ her did according to the death certificate?
deceased he/she gender? he/she
member of when died? Ano ang dahilan ng pagkamatay
the family? he/she Ano ang ayon sa Death Certificate?
died? kanyang Kailan
Ano ang kasarian? siya
pangalan na Ilang namatay
namatay na taon na ?
miyembro siya
ng pamilya? nang
siya ay
mamata
y?