UNIVERSITY OF SAINT LA SALLE

COLLEGE OF NURSING
BACOLOD CITY

COMMUNITY HEALTH NURSING

Community Health Profile Worksheet
(Worksheet “C”)

Part I: ASSESSMENT OF THE FAMILY

Head of Family: Mario Perez Family Number: 4

Address: Purok Balabag, Hacienda Sto. Domingo, Barangay Granada

MEMBERS OF THE HOUSEHOLD

RELATIO SE BIRTHDAY A MARITAL STATUS/ HIGHES

FAMIlY N TO X Month/day/yea G RELIGION T OCCUPATION
MEMBER HEAD r E EDUC
COMPL
ETED
N Name TYPE
o. OF PLAC
WORK E
1. Mario Husband M November 2, 55 Married Catholic High- Family
Perez 1966 school driver of
graduate the
landowner
Lorna
2 Wife F October 17, 53 Married Catholic College Housewife
2. Perez 1968 graduate
John Kevin Children M June 14, 27 Single Catholic College Teacher
Perez 1994 graduate
3.
Juan4 Children M April 12, 24 Single Catholic College Teacher
Miguel 1994 graduate
4. Perez

1. Types of Family Structure: Nuclear___✔_____ Extended___________

2. Family Size:
• Small (1-4 members)___✔________
• Medium (5-6 members)_________
• Large (7 members and up)_______

Part II. THE EIGHT SUBSYSTEMS:

I. HOME AND PHYSICAL ENVIRONMENT

1. Types of Dwellings:
• Concrete______✔__________
• Wood _________________
• Concrete-wood___________
• Makeshift_______________
• Others: Please specify:______________________
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2. Do you have a backyard? Yes___✔____ No_______

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3. Residency/length of Stay:
• Month/s__________________
• Years_______✔_____________
• Others: Please specify_______________________

4. House ownership:
• Owned________✔_________________
• Rented_________________________
• Rent-free_______________________
• Others: Please Specify______________________________

5. Land Ownership:
• Owned_______________________________
• Rented_______________________________
• Squatter______________________________
• Others: Please Specify: Owned by their employer

6. Do you have domestic animals?

No______✔_______ Yes____________, What are these?___________________
_______________________________
_______________________________

7. What kind of weather does your community usually have?: Summer and Rainy season

8. Does your community experience natural calamities?

No_____________Yes_____✔_______, What are these? Typhoon, flood and
sometimes earthquake

9. Where do you usually go if you experience these? They usually stay in their house.

10. Are there reported cases of crimes in your community?

No______✔_______Yes_____________, What are
these?___________________

11. Are there reported cases of drug addiction in your community?

No______✔_______Yes_____________

12. Do you have electricity?

No_____________Yes_____✔________
13. Means of Cooking:
• Electric Stove________________________________
• Wood______________________________________
• Charcoal____________________________________
• Kerosene____________________________________
• LPG___________✔_____________________________
• Others: Please Specify:________________________

II. EDUCATION:

1. Are there household members who are presently attending school?

Yes____________No_____✔_____

If yes, What level?______________________________________________

What is the name of the school?_____________________________________

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 Where is the school located?________________________________________
If no, why? They all finish college and already had a work.

2. Are there schools in the community?

Yes_______✔__________ No______________________
If yes, What are these? Emiliano Lizares National High School and Generoso Villanueva Sr.
National High School

3. What are the educational facilities of the school in your community? School Clinic

4. Is there a school clinic? Yes______✔_______No__________________

If no, why?_________________

5. What are the health services offered by the school nurse? Gives deworming medications,
vitamin A supplements and other medical services such as wound dressing and first aid kit.

6. Do people go to school outside the community? Yes__________No_____✔_______

` If yes, What school?
7. Is there any nutrition program available in your school?Yes_________No____✔______
If yes, What is this?_______________________________________________
8. Are there night school in your community? Yes_____________No_______✔_________
If yes, What school?
Do you avail of this night school program? Yes_____________No _______✔_________
If no, why? Because they don’t have night
school

9. Are there schools in the community for special children?Yes________No____✔_______

If yes, What school?_____________________
_____________________________________
10. Are there vocational schools in the community? Yes___________No______✔_________
If yes, What school?_____________________
______________________________________
11. Are there PTA’s in the school? Yes_____________ No______✔_________
Are you a member? Yes___________ No__✔_________

III. SAFETY AND TRANSPORTATION

1. Food Storage:
• Refrigerator____________✔_______________________
• Without refrigerator but with cover________________
• Others: Please specify___________________________

2. Source of Drinking water:

Deep Well____________ Communal faucets_______________
Rain water____________ Distribution (pipeline)____________
River/stream__________ Others: Please specify Purified Water
Artesian Well_________

3. Storage of Drinking Water”

With cover________✔________ Without cover_________________
What kind? They store it inside a refrigerator

4. Is the water safe for drinking? Yes______✔________ No____________

If no, what do you do before drinking the water?_______________________

5. Do you have your own drinking glass? Yes______✔________ No_________________

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 If no, why?_____________________________________________________

6. Do you have good quality of air in the community? Yes_____✔______ No___________

If no, why?______________________________________________________

7. How do you dispose your garbage?

▪ Compost pit_____✔________
▪ Burning________________
▪ Collected_______________
▪ Open dumping___________
▪ Others: _________________

8. Do you practice waste segregation? Yes _______________ No _____✔________

If no, why? They don’t segregate their garbage but instead they put it in the
plastic bag and throw it in communal pit.

9. Do you have a toilet? Yes_____✔_______ No______________

▪ Pit privy____________
▪ Water sealed________
▪ Septic Tank_________
▪ Others: Please specify: Pour Flush
▪ If no, why?_________________________________
10. Are there barangay tanods in the community? Yes_____✔________ No
_______________

11. Are there public transportations available in the community? Yes ✔ No_______
If yes, what are these? Jeepney and Tricycle
If no, why?________________________________________________________

12. Is there a fire station in the community? Yes_____✔________ No______________

How many fire trucks are available? 2

13. Are there Police outposts in the community? Yes ____✔____ No _______________
If no, why?__________________________________________________

14. Who is/are the person/s responsible in resolving conflicts in the community?
Barangay Captain___✔___
Tanod _______________
Police_______________
Relative_____________
Neighbors___________
Others: ______________
15. Is your community generally peaceful? Yes_____✔______ No______________
If no, why?_______________________________________________

16. Are there household pest? Yes____✔_______ No_____________

If yes, what are these? Rodents, mosquitoes, cockroaches, flies, and ants.

17. How do you destroy the pests? They did not mention

IV. POLITICS AND GOVERNMENTS

1. Do you know your purok leader? Yes_________✔_________ No________________

If yes, What is his/her name? Luisito Tabujara
If no, why? _______________________________________________
2. Do you know your barangay captain? Yes___✔_______No_________________
If yes, What is his/her name? Alfredo Talimodao

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 If no, why?_______________________________________________
3. Do you exercise suffrage during election? Yes_____✔______ No____________
If no, why?_______________________________________________
4. Do you have peaceful elections in your community? Yes___✔____ No_________
If no, Why?________________________________________________
5. Are you a member of an organization, club, or association in your community?
Yes______________ No ______✔_________
If yes, What organization/club/association?________________________
What is your position? ________________________________________
If no, why? Did not mention
6. Where do you run to when you need help?
Barangay Captain______✔______ Priest/Ministers_____________
Purok Leader________________ PTA President______________
Councilman_________________ Landowners________________
Teachers___________________ Club Officers ______________
Others: Please specify;________________________________________

VI. HEALTH AND SOCIAL SERVICES:

1. Is there presently a sick family member? Yes _____✔_____ No __________________

If yes, Name: Lorna Perez Age: 53 Sex: Female
Type of ailment: Type 2 diabetes Mellitus
Duration of ailment? Did not mention
Is anybody attending the sick member? Yes _______________ No_____✔__________
If yes, who is attending him/her?
• Doctor____________________
• Nurse_____________________
• Midwife___________________
• Herbolario_________________
• Others: Specify_____________
• None_________________
why?______________________________
2. Immediate dead family member? ___________________________________________
Cause of death__________________________________________________________
3. How often do your family members get sick?
▪ Once a year__________✔___________
▪ Twice a year____________________
▪ Several times ___________________
▪ Others_________________________
4. Common ailments of the family during a year?
• Fever_______✔__________
• Colds_________________
• Flu___________________
• Diarrhea_______________
• Cough_______✔_________
• Stomach Ache__________
• Toothache_____________
• Others: Specify Diarrhea
5. Where do you usually go when you get sick?
BHS________✔__________
Private Clinic___________
Hospital______________
Others: ________________
6. Whom do you go to when you get sick?
Doctor _______✔__________
Nurse __________________

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 Midwife________________
Herbolario_____✔ for minor ailments, they seek traditional healer.
Others_________________
7. What medicines do you usually take when you get sick? She usually buy medicine
according to what she hears and see in tv and radio
8. Are these medicines prescribed by doctors? Yes ____________ No ________✔________
If no, why? She usually buy medicine according to what she hears and see in
radio and tv.
9. Do you have herbal plants in your backyard? Yes ___________ No _____✔____
If yes, what are these? _____________________________________________
If no, why? She only plants vegetable
10. For what ailments do you use them? _________________________________________
11. Do you use a method in family planning? Yes ___________ No ___________________
If yes, what method?_______________________________________________
If no, why?_______________________________________________________
12. From whom do you learn about the method/s in family planning?
▪ Neighbour_____________________________
▪ Friend________________________________
▪ Relative_______________________________
▪ Midwife_______________________________
▪ Nurse_________________________________
▪ Doctor________________________________
▪ Priest/Ministers_________________________
▪ Others: Specify__________________________
13. Whom do you consult when you are pregnant?
Doctor_____________________
Nurse_______________________
Midwife_____________________
Trained hilot__________________
Untrained hilot________________
Others: Specify________________
14. Were you given tetanus toxoid immunization? Yes _________ No ___✔_______
15. Where do you deliver your baby?
Home_______________________
RHU________________________
Private Clinic_________________
Hospital_____________________
Others: Specify________________
16. Do you breastfeed your baby? Yes _________ N o _____________
If yes, for how long?
If no, why?______________________________________
17. Do you give milk formula to your baby? Yes __________ No _______________
If yes, what milk formula? ____________ for how long______________
If no, why __________________________________________________
18. Do you give both milk formula and breastfeeding? Yes ________ No ___________
If yes, why?__________________________________________________
If no, why?___________________________________________________
19. At what age do you give supplementary feeding to your baby?_________________
What kind of supplementary food?_______________________________________

20. How often do you eat the following food?

FOOD DAILY EVERYWEEK 2X A WEEK ONCE A ONCE A
WEEK MONTH
Vegetable ✔
Fruits ✔
meat/poultry ✔
rice/rootcrops ✔
legumes ✔
fish ✔

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21. How many of your children are very thin____0____, pale______0_____, with big
abdomen_____0________, with skin disease ____0_______?
22. Do you submit your children for immunization? Yes ______✔______ No
______________
If yes, DPT____________
BCG____________
POLIO__________
HEPA B_________
MEASLES_______
HBS Ag__________
FLU_____________ Others:Specify Did not mention what immunization
23. Do you have Botika in your barangay? Yes ____________ No_____✔______
If yes, Do you get your medicines from this botika?____________________
If no, why? Did not mention if there are any botika in their barangay
24. Do you have a hospital in the community? Yes __________ No_____✔______
If yes, what is the name of the hospital ________________________
Do you avail of the services in the hospital? Yes_____ No ________
If yes, what are the services?________________________________
If no, why?______________________________________________
How do you get to the hospital?
• Walk_________________
• Car__________________
• Jeep__________________
• Tricycle_______________
• Tricykad_______________
• Others: Specify__________

25. Do you have the following health care facilities/services in the community?
Clinical laboratory______________
Ultrasound Laboratory___________
Xray Laboratory________________
Others: Specify_________________
26. Do you avail of these services? Yes_________ No __________________
27. How do you get to these facilities?
Walk_________________________
Jeepney_______________________
Car___________________________
Tricykad_______________________
Tricycle _______________________
Others: ________________________
28. Do you avail of the services in the BHS? Yes_____✔________ No_______________
If yes, What are these services? Immunization
How often do you avail of the services?
Very often__________________
Often_______✔_______________
Seldom____________________
Very Seldom________________
If no, why? ____________________________________________________
29. How do you get to the BHS?
Walk_________✔____________
Jeepney___________________
Car_______________________
Tricykad__________________
Tricycle___________________
Others:____________________
30. Who is the source of your health information?
Doctor______________
Nurse_______________
Neighbor____________
Herbolario____✔_______
Others:______________

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VI. COMMUNICATION:

1. Do you read newspapers? Yes _____________ No_____✔________

If yes, what newspaper?___________________________________
How often do you read?___________________________________
If no, why? They only watch tv.
2. Aside from newspapers, do you read other printed materials? Yes _______ No__✔____
If yes, what are these?___________________________________________________
How often do you read?__________________________________________________
If no, why?____________________________________________________________
3. Do you listen to the radio? Yes ____________ No________✔_______________
If yes, AM____________FM_______________
How often do you listen?__________________
If no, why? They only watch tv.
4. Do you watch television? Yes ___✔_______ No____________
If yes, What program? Name of Program/TV Network
News____________ ________________________
Telenovela____✔____ ________________________
Variety Shows_____ ________________________
Game Shows______ ________________________
Cartoons_________ ________________________
Talk Shows _______ ________________________
Others____________ ________________________
How often do you watch? Everyday
If no, why?______________________________________________________

5. Do you have the following entertainment/communication facilities at home?

Television____________✔_______________
Radio_______________________________
Computer with internet_________________
Computer without internet_______________
Telephone____________________________
Cellphone____________________________
Others _______________________________

6. How many household members have cell phones? _________4___________

7. Where do you usually use the cell phones/telephone? Emergencies

8. How do you contact in case of emergency?

Telephone_________________
Cellphone_______✔___________
Both______________________

9. Do you have post office in the community? Yes______________ No____✔______

If yes, where is it located?_____________
Do you avail of the postal services? Yes ________ No________________

10. Do you have purok meetings? Yes_____✔______ No_____________

If yes, do you attend the meetings?____________________
How often do you have the purok meetings? Every month
If no, why?_______________________________________

11. Do you have the following communication facilities in the community?

Radio stations______✔_________
TV stations_________✔________
Telephone Company__________
Cell Sites___________________

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 Others: ______________________

VII. ECONOMICS:

1. What is the family’s monthly income? P35,000-40,000 per month

2. What are the family’s monthly expenses?

Budget Food Electricity House Clothes Water Health Education Leisure

9,000 ✔
2,000 ✔
5,000 ✔
200 ✔
1,000 ✔
5,000 ✔
Total 22,2000

3. Do you have income generating projects? Yes___________ No____✔________

If yes, what? ___________________________
If no, why? Did not mention.

VIII. RECREATION:

1. What are the recreational sites that can be found in your community? Outside the
community?_____________________________________________________________
Do you avail of these facilities? Yes ___________ No_____________
If no, why?______________________________________________________________

2. Do you engage in any sport? Yes _____ No____✔____

If yes, what sports?
If no, why?

3. Does your community have any sports facilities? Yes_____✔______ No___________

If yes, what sports facilities? Basketball court and Football field.
If no, why?______________________________________________________________

4. Do you play any card or board games? Yes__✔____ No___________

If yes, what game/s? Monopoly
If no, why?__________________________________________________________

5. Do you have any tourist spots in your community? Outside the community?
Yes_______________ No_____✔________
If yes, what is/are the name/s of the tourist spot/s?____________________________

6. Are there movie houses in the community? Outside the community? Yes______ No_✔__
If yes, do you watch movie?_________________ How often?___________________
What kind of movie do you usually watch?___________________________

7. Are there Churches or religious services available in the community? Yes___ No_✔___
If yes, what are the types of church and religious services?____________________
____________________________________________________________________

8. Do you participate in the church or any religious activities? Yes ____ No___✔_____
If no, why? Did not mention

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9. Do any churches provide recreational activities or facilities? Yes ______No____✔___
If yes, what activities/facilities?___________________

10. Are there social committees, organizations or clubs available in the community?
Yes___________ No____✔_______
If yes, what are these organizations/clubs/committees?____________________
Are you a member of any of these?____________________________________

Informant: Lorna Perez Surveyed by: Jyniel Cagape

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