Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES

Tamag, Vigan City
2700 Ilocos Sur
COLLEGE OF HEALTH SCIENCES
Website: www.unp.edu.ph email: chs_unp@yahoo.com
Tel No.: +639177708873

COMMUNITY HEALTH SURVEY

Barangay/Municipality: ___________________________________

Head of the Family: ____________________________________________________________________________

A. Structure of the Family

Relationship to Age/ Civil Highest Educational Blood
Name of Family Member Occupation Remarks
the Head Sex Status Attainment Type

B. Environmental Conditions
1. Toilet Type:  Flush Toilet  Pit Privy  Water sealed  None/Others:_________________
2. Drainage Type:  Open Blind
3. Garbage Collection & Disposal :  Composting  Open Dumping  Burning  Others:___________________
4. Source or Drinking Water:  NAWASA Water Pump  Deep Well
 Unprotected Spring  Others: _____________________
5. Food Storage:  Cabinet  Refrigerator  Covered with Plate  basket  Others: ___________
C. Beliefs and Practices
What are your Beliefs and Practices on the following?
A. Health Promotion Practices: _____________________________________________________________________

B. Pregnancy and Child Birth:______________________________________________________________________

C. Child Feeding: _______________________________________________________________________________

D. Food Preparation: ____________________________________________________________________________

E. Food Preference: _____________________________________________________________________________

F. Medicine Preferences if illness has occurred: ________________________________________________________

G. Treatment Preferences if illness has occurred: _______________________________________________________

D. Health History
Consulted
Name Illness Medication Used the Doctor? Others:
(Y/N)
 Republic of the Philippines
UNIVERSITY OF NORTHERN PHILIPPINES
Tamag, Vigan City
2700 Ilocos Sur
E. Community Health Needs and Problems
1. How would you rate our community as a “ Healthy Community?”
 Very Unhealthy  Unhealthy  Somewhat Healthy  healthy  Very Healthy
2. How would you rate your own personal health?
 Very Unhealthy  Unhealthy  Somewhat Healthy  healthy  Very Healthy
3. How would you rate your Family’s health Status in general?
 Very Unhealthy  Unhealthy  Somewhat Healthy  healthy  Very Healthy
Aside from illness/diseases acquired, is there any other health problems occurred in our community that needs attention?
1. ___________________________________________________________________________________________
2. ___________________________________________________________________________________________
3. ___________________________________________________________________________________________
4. ___________________________________________________________________________________________
5. ___________________________________________________________________________________________

Do you have any recommended solutions from the above mentioned Health Problems?
1. ___________________________________________________________________________________________

2. ___________________________________________________________________________________________

3. ___________________________________________________________________________________________

4. ___________________________________________________________________________________________

5. ___________________________________________________________________________________________

Others:

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Signature of Interviewee Date Time

____________________________________ _________________________________
Signature Over Printed Name of Interviewer Clinical Instructor