Western Mindanao State University

COLLEGE OF NURSING
Zamboanga City

BSN LEVEL III

IST SEMESTER S.Y: 2021 – 2022

COMMUNITY HEALTH ASSESSTMENT FORM

Instruction: Answer the following given situation below. You may browse through internet a
particular community where you belong.

A. Collect data on population, statistics, location and social system of a chosen community,

including the history.

B. Include the geographical map of the community and highlight important landmarks.

C. Interview a member of a family/household within the community.

D. Based on the data collected, make a list of community health problems.

E. Rank the identified problems using priority setting process

F. Formulate a Community Nursing Care Plan based on the identified problems

Respondent: Age:
 Status: Sex:
Relation to Head: (If not the Head of the Family)
I. Family Data
A. Head of the Family Age
B. Name of Spouse
Age
C. Address

D. Educational Attainment:
i. Husband
ii. Wife
E. Length of Residency
F. Ethnic Origin
G. Type of Family
H. Religion
I. No. of Children
J. Members of the Household
K. Family life styles: Basic life style of family, decision-making pattern, family relationship
& communication, family response in crisis situation, family attitude towards health

L. Family Data Base:

NAME AGE SEX STATUS EDUCATIO OCCUPATIO

N N

II. Socio-Economic Data: Determine socio- economic status of the community

 A. Sources of Income:
i. Government:
ii. Private
iii. Self-employment
iv. Unemployment

III. Housing & Environmental Condition of the Community

a. Type of Community

b. Home Types: Concrete, wood, mixed, makeshift, etc .

c. Surroundings: presence of mosquitoes, flies, rodents

d. Source of Water Supply: Artesian well, deep well , Water District, others

e. Source of Drinking Water

f. Toilet Facilities: Sanitary, unsanitary:

g. Garbage Disposal: Collection, burning, burying, open dumping, garbage cans , etc.

h. Presence of Animals

i. Backyard Gardening; Vegetables, herbal, fruits

j. Relationship among neighbors

k. Festival celebration: a. In community b. In family

IV. FACTORS influencing health within the family and community as a whole

1. Common health habits

Income and social status

Social support networks
Education and literacy
Employment / working conditions
Social environments
Physical environments
Personal health practices and coping skills
Healthy child development
Biology and genetic endowment
Health services
Gender
Culture
 For the purposes of this report, five factors affecting health are discussed:
Housing
Poverty
Safety
Sense of belonging
Transportation

2. Concept about health

Income and social status

Social support networks
Education and literacy
Employment / working conditions
Social environments
Physical environments
Personal health practices and coping skills
Healthy child development
Biology and genetic endowment
Health services
Gender
Culture

3. Concept about disease

Income and social status

Social support networks
Education and literacy
Employment / working conditions
Social environments
Physical environments
Personal health practices and coping skills
Healthy child development
Biology and genetic endowment
Health services
Gender
Culture

4. Care during pregnancy

Income and social status

Education and literacy
Social environments
Physical environments
Culture

5. Care of infant

Income and social status

Education and literacy
Social environments
Physical environments
Culture

6. Concept about education

Income and social status

Education and literacy
Social support networks
Social environments
Physical environments

7. Knowledge & attitudes of people towards health

Income and social status

Education and literacy
Social environments
Physical environments
Healthy child development
Culture

Income and social status

Social support networks
Education and literacy
Employment / working conditions
Social environments
Physical environments
Personal health practices and coping skills
Healthy child development
Biology and genetic endowment
Health services
Gender
Culture
For the purposes of this report, five factors affecting health are discussed:
Housing
Poverty
Safety
Sense of belonging
Transportation

V. Family Health- health-seeking behaviors, health practices

VI.Nutrition- Food Sources; attitudes towards eating, food preferences, nutritional problems:
 malnourishment, undernourishment, obesity, eating disorders, etc.

VII. C ONCEPT ON CHRONIC and ACUTE HEALTH CONDITIONS

- Any chronic/ conditions within the family: Infectious diseases, Diabetes

Mellitus, Hypertension, Cardiac diseases, Blood disorders, Cancer of any
kind, Mental Illness, etc.

- Treatment regimen: Maintenance drugs, therapeutic approaches,

chemotherapy, etc.

- Nursing / Home care

- Alternative medicines, folk treatment, traditional approaches, etc.