REPUBLIC of the PHILIPPINES

City of Makati
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal Extension, West Rembo, Makati City 1215
Telephone No. : (+632) – 881 – 1571
_____________________________________________________________________________________
CENTER OF NURSING

QUESTIONNAIRE
Family Structure, Characteristics and Dynamics and Socio-Economic Status

Name Age/Sex Relationship Educational >8 yrs. old >18 yrs. old
Attainment Can read or write Civil Religion
Status
Genitha Medidas Ramos 56 | F Mother Undergrad Yes Married Roman Catholic
Jenny Lou Ramos 27 | F Daugther Undergrad Yes Married Roman Catholic
Marbones
Rev Franco Marbones 5|M Son No Single Roman Catholic
Louwella Faith Ramos 20 | F Sister College Yes Single Roman Catholic
Sophia Ysabel 13 | F Sister High School Yes Single Roman Catholic

Length of residency in the >18 yrs. old If employed,

barangay Place of origin Employed/Specify Monthly Income
28 years Tubigon , Bohol Unemployed
27 years Makati City Employed 20,000
5 years Makati City NA
20 years Makati City NA
13 years Makati City NA

Type of Family

☐ Nuclear Family ☐ Extended Family ☒ Single Parent ☐Dyad Family ☐ Cohabitation Family

Home and Environment

Lot
☒ Rented ☐ Owned ☐ Others (Specify)____________
House
☒ Rented ☐ Owned ☐ Others (Specify)____________
Type of House
☒ Concrete ☐ Wood ☐ Mixed ☐ Makeshift ☐ Others (Specify)____________

Environment

Lighting
☒ Adequate ☐ Inadequate

Ventilation
☒ Adequate ☐ Inadequate
 REPUBLIC of the PHILIPPINES
City of Makati
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal Extension, West Rembo, Makati City 1215
Telephone No. : (+632) – 881 – 1571
_____________________________________________________________________________________
CENTER OF NURSING
Water Supply
☐ Level 1 ☐ Level 2 ☒ Level 3 Others: (Specify)
(Point Source) (Communal (Waterworks _________
Protected or deep Faucet System) System)
well > 250 m away Protected or deep Piped distribution
well < 25 m away and household
taps

Excreta Disposal
☒ Sanitary Toilet ☐ Unsanitary Toilet Facility ☐ No Toilet Facility

Facility
Garbage/ Solid Waste/ Refuse Disposal
☐ Open ☐ Dumping ☐ Burying ☒ Collected ☐Burning ☐ Others (Specify)_______________

How far away from household? _________

Pet Ownership/ Domesticated Animals

☐ If any (Specify) _________ How far away from household? _________

Pet/ Domesticated Animals Food Source

☐ If any (Specify) _________

Health Status and Values, Habits and Practices on Health Promotion, Maintenance and Disease Prevention
Food Storage
☐ Covered
☐ Uncovered ☒ Refrigerated ☐ Others (Specify)_______________
Water Storage
☒ Covered☐ Uncovered ☐ Refrigerated ☐ Others (Specify)_______________

Is there an infant?
☐ Yes ☒ No (Skip Next 2 Questions)

Infant Feeding

☐ Exclusive Breastfeeding ☐ Formula ☐ Mixed/Specific Formula_______________

Immunization Status

☐ BCG ☐ DPT 1 ☐ DPT 2 ☐ DPT 3

☐ OPV 1 ☐ OPV2 ☐ OPV 3
☐ Hepatitis B1 ☐ Hepatitis B2 ☐ Hepatitis B3 ☐ AMV
 REPUBLIC of the PHILIPPINES
City of Makati
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal Extension, West Rembo, Makati City 1215
Telephone No. : (+632) – 881 – 1571
_____________________________________________________________________________________
CENTER OF NURSING
Health Seeking Behaviors
Common Illness for the past 6 months, Specify ___none_____________
Common Illness for the past 1 year, Specify ______none__________
Where did you seek health care?
☒ Barangay Health Center ☒ Private Clinic ☐ Hospital ☐ Private
☐ None ☐ Others (Specify)______

Nearest Health Center Facilities ________Barangay Rizal Health Center_________________________

Nearest Government Hospital ___Ospital ng Makati / Osmak______________________________
Nearest Public School _________Rizal Elementary School_______________________
Nearest Public Transportation Terminal ___None____________________________

Communication

Where do you get health information from?

☒ Health Center Personnel ☐ Television ☐ Newspapers/Fliers/Posters ☐ Radio
☐ Phone ☐ Others (Specify)______

Family Planning
Are you practicing family planning?
☒ Yes ☐ No (Skip Next Question)

What methods are you using?

☒ Temporary (Pills, Condoms, IUD, Diaphragm, Cervical Cap)
☐ Permanent (Tubal Ligation, Vasectomy)

Pregnant Mother
Are you pregnant? ☐ Yes ☒ No (Skip Next
Question)
Prenatal Check-up ___________________________________

Direction: Please check (√) and evaluate honestly the responses of barangay officials to the common problem
of the Barangay Rizal.
 REPUBLIC of the PHILIPPINES
City of Makati
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal Extension, West Rembo, Makati City 1215
Telephone No. : (+632) – 881 – 1571
_____________________________________________________________________________________
CENTER OF NURSING

5- Strongly Agree 4- Agree 3- Neutral 2- Disagree 1- Strongly Disagree

QUESTION 5 4 3 2 1
I am satisfied with the ordinances implemented by the barangay. √
Problems in our barangay affects our current situation. √
I am satisfied with the sanitation of our barangay. √
Projects conducted in promoting environmental conservation. √
“Ayuda” where been given relatively. √
 Communication with residents in dealing pollution. √
The peace and order in the Barangay. √
I am satisfied with the health facilities present in our barangay. √
Emergency response team were present. √
Barangay officials are doing their job in promoting and ensuring the cleanliness of √
the barangay.
There have been projects conducted in the past that promote environmental √
conservations.
The barangay communicates with the residents in dealing with pollution and other √
calamities that they might experience.
The barangay is keeping their protocols well done about COVID-19 and residents √
Are obediently following it.
I have been affected by diarrhea in our barangay. √
I have been affected by upper respiratory disease. √
I have been affected by malnutrition. √
High birth rate. √
My job have been affected by the pandemic. √
I am satisfied with the cost of medicines in our barangay. √