PHINMA University of Pangasinan

Dagupan City, Pangasinan

COMMUNITY HEALTH ASSESSMENT

Respondent: Age:
Stage: 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: Tel.No:
D. Educational Attainment
i. Husband:
ii. Wife:
E. Length of Residency:
F. Ethnic Origin:
G. Family:
Nuclear ( ) Extended ( )
H. Religion:
I. No. of Children:
J. Members of the Household:

Name Age Sex Status Education Occupation

1.
2.
3.
4.
5.
6.

II. SOCIO ECONOMIC DATA

A. Source of Income
Occupation:
Husband:
Wife:
Employed ( ) Unemployed ( ) Self-employed ( )
Monthly Income:
Below Php 2, 000 ( ) Php 2, 000 – Php 5, 000 ( )
Php 5, 001 – Php 8,000 ( ) More than Php 8, 000 ( )
B. Family Expenditures
1. Food
Below Php 50.00 ( ) Php 50.00 – Php 75.00 ( )
More than Php 70.00 ( )
 2. Clothing number of times of buying
Once a year ( ) Twice a year ( )
Thrice a year ( )

3. Housing
Water ( ) Electricity ( )
Telephone ( )
4. Schooling
Public ( ) Private ( )

5. Others:________

III. HOUSING & ENVIRONMENTAL CONDITIONS

A. Home
Type:
Concrete ( ) Wood ( )
Mixed ( ) Makeshift ( )
Others:_________
Ventilation:
Poor ( ) Good ( )
Lighting:
Adequate ( ) Inadequate ( )
Surroundings:
Clean ( ) Dirty ( )
B. Source of Water Supply
Artesian well ( ) Deep well ( )
NAWASA ( ) Others:_________
C. Storage of Drinking Water
Refrigerated ( ) Covered ( )
Uncovered ( )
Containers used:________

D. Toilet Facilities
Sanitary:
Flush ( ) Pit privy ( )
Shared ( ) Owned ( )
Others:
Unsanitary:
“Ballot system ( ) Others:______

E. Garbage Disposal
Collection ( ) Burning ( )
Burying ( ) Open dumping ( )
Garbage cans ( ) Others:_______
F. Food Storage
 Covered ( ) Uncovered ( )
Refrigerated ( )

G. Presence of Animals
Dogs ( ) Cats ( )
Pigs ( ) Others:_________

H. Backyard Gardening
Vegetables ( ) Herbal ( )
Fruit – bearing ( ) Others:_________

IV. COMMUNITY RESOURCES

A. Health and Other Facilities
Health center ( )
School ( )
Park ( )
Public Hospital ( )
B. Indigenous health workers
Trained “hilot” ( )
“Herbularyo” ( )
Barangay hall ( )
Church ( )
Market ( )
Private clinic ( )
Private hospital ( )
Untrained “hilot” ( )
Others:

C. Sources of health funds

Government ( ) Private ( )
NGOs / POs ( ) Others:________

V. NUTRITION
A. Food preference
Fish ( ) Fruits / vegetables ( )
Meat ( ) Mixed ( )

B. Common
Rice & egg ( ) Rice & sardines ( )
Rice & noodles ( ) Others:_______
C. Presence of Nutritional Disorder
1. Goiter
Enlargement of the neck ( ) Dysphagia ( )
Hoarseness ( ) Others:_______

2. Anemia
Pallor ( ) Easy fatigability ( )
Body weakness ( )

3. Vitamin A deficiency
Night blindness ( ) “Pilak sa mata”
Others:_______

4. Others:______

VI. KNOWLEDGE, ATTITUDE & PRACTICE

A. Do you utilize the health center? Yes ( ) No ( )

If no, why? ________________________

B. Reason:
Illness ( ) Prenatal ( )
Family Planning ( ) Postnatal ( )
Dental ( ) Nutrition ( )

C. First Person consulted in times of illness:

M. D. ( ) Nurse ( )
Midwife ( ) “Hilot” ( )
“Herbularyo” ( ) BHW ( )
Others:________

D. Usual illness in the family

What do you do for this condition?
Self – medication ( ) Consultation ( )
Hospital ( ) Private clinics ( )
Nursing ( ) Others:______

E. Others diseases
TB ( ) Leprosy ( )
Skin disease ( ) Hepatitis ( )
Others:______

F. Do you submit your children ( 0 – 12 months) for immunization? YES ( ) NO ( )

Name of child birthday immunization:

BCG ( ) DPT ( ) OPV AM ( )

G. Do you practice family planning? Yes ( ) No ( )

Method:
If no, why?____________________

H. Method of infant feeding

Breast ( ) Bottle ( )
Mixed ( )

I. Subjects you want to learn in health education

Drug abuse ( ) Nutrition ( )

Family planning ( ) Herbal plants ( )

First aid measure ( ) Others:_________

Interviewed by:

Date: Time: