HOLY INFANT COLLEGE

Nursing and Midwifery Department

Tacloban City

COMMUNITY HEALTH SURVEY FORM

Date of Interview:____________ Interviewer:____________________________________

Household Number:__________ Respondent:___________________________________
Zone:___________ Age:__________________ Sex:____________________
Barangay:______________________ Relation to Head:__________(If not Head of the Family)

I. FAMILY DATA
A. BASIC INFORMATION ABOUT HEAD OF THE FAMILY
Name:(Husband)_____________________________Age:_____Sex:_____CivilStatus:_________
Occupation:________________________Employment Status:_______ Private Employee
Educational Attainment:______________ _______Government Employee
_______Self-Employed
_______Unemployed
Family Type:________ Nuclear ________Extended

B. BASIC INFORMATION ABOUT THE WIFE AND OTHER FAMILY MEMBERS

Occupation
Relation Highest For 6 yrs old & above
NAME to Head Age Sex Civil Status Educational (pls. indicate if still
of the Attainment for studying/working &
Family 6 years old & type of work)
above

II. SOCIO-ECONOMIC AND CULTURAL DATA

 A. RELIGION (Please state) _______________
B. Estimated AVERAGE FAMILY INCOME PER MONTH (Total from All Sources)
__________ P 8,001 & above __________ P 2,001 – P 5,000
__________ P 5,001 – P 8,000 __________ P 2,000 & below
C. PRIMARY SOURCE OF INCOME of the Head of the Family
Check () only one main source of income.
_______ Carpentry _______ Peddling
_______ Farming _______ Small Industries (Sari2x store, carenderia, shop, etc.)
_______ Fishing _______ Tuba Gathering
_______ Laborer _______ Others (Specify): ____________
D. Other Sources of Income (FOOD PRODUCTION ENGAGED BY HOUSEHOLD)
Check () those that are applicable.
_______ Fruit Trees _______ Poultry ________ Others (Specify):
_______ Piggery _______ Vegetable Gardening _____________

III. HEALTH DATA

A. MORBIDITY (Past 2 years) – from year 2019 up to present.
May-ada ba nagkasakit ha iyo pamilya ha sulod han nakalabay nga duha ka tuig?
NAME ILLNESS HEALTH SERVICES PRESENT HEALTH CONDITION

B. MORTALITY (Past 5 years) from year 2007 up to present.

May-ada ba namatay ha iyo pamilya ha sulod han nakalabay nga lima ka tuig?
CAUSE OF
NAME DEATH/DIAGNOSIS DATE OF DEATH HEALTH SERVICES RECEIVED

IV. MATERNAL AND CHILD HEALTH DATA

A. PRENATAL, NATAL & POST-NATAL
(To be answered if there were PREGNANT/LACTATING MOTHERS AND DELIVERIES IN THE
PAST 5 YEARS).

Yes____ No____ 1. Is there a pregnant or lactating mother in the family?

Name of Pregnant Mother:______________________ Age:_________
Date of Last Menstrual Period: (LMP): _____________
Gravida ____ Term ____ Preterm ____ Abortion ____ Living ____
Yes ____ No____ 2. Does the pregnant mother go on prenatal visits?
a. When was her first prenatal visit? ___________
b. Does she have at least one visit per trimester? Yes ____ No ____
(Pls. ask for the dates of prenatal visits made by the pregnant mother).
First Trimester Second Trimester Third Trimester
___________ ___________ __________
___________ ___________ __________
___________ ___________ __________
c. Total number of prenatal visits:______
Yes____ No____ 3. Did the pregnant or lactating mother was provided with iron & iodine
supplement?
Yes____ No____ 4. Does the pregnant mother was given at least 2 doses of tetanus toxoid?
Yes____ No____5. Are there deliveries handled by trained health personnel in the past 5 years?
 Applicable to mothers with children aging 5 years old & below.
 NAME OF CHILD DATE OF BIRTH AGE BIRTH ATTENDANT (Physician,
Nurse, RHM, Trained Hilot)

B. FAMILY PLANNING PROGRAM

(To be answered if there are MCRAS in household)

Yes____ No____ 1. Are there couples who have access to family planning services?
Yes____ No____ 2. Are there couples practicing family planning methods?

REASON FOR NOT USING ANY

NAME OF COUPLES AGE METHODS USED LENGTH OF USE FAMILY PLANNING METHODS

C. FOOD/NUTRITION AND IMMUNIZATION STATUS

C1. BREASTFEEDING PRACTICES (For household with children 0-2 years old).

1. Is there an infant who is exclusively breasted for six months? Yes____ No____
If NO, check only one reason of the mother for not breastfeeding her child.
____illness ____working
____inadequate milk ____others(specify):________
2. Method of infant feeding:
____breastfeeding ____bottle feeding ____mixed feeding
3. Length of breastfeeding.

AGE OF CHILD WHEN

NAME OF CHILD BREASTFEEDING WAS STOP LENGTH OF BREASTFEEDING

C. 2. SUPPLEMENTAL FEEDING (For Household with children 4 months – 2 years old).

NAME OF CHILD AGE STARTED TYPE OF FOOD (Enumerate)

C.3. NUTRITION STATUS (For Household with children 0-72 mos. old).
Name of Child Ag Sex Date of Birth Date Weight in Nutritional Name of Mother
e Weighed Kilograms Status

C.4. IMMUNIZATION STATUS

Do you submit your children 0-12 months for immunization?

Name of Child Date A S Immunization Received Immuni Name

of g e (For each column indicate the date when vaccine received) zation of
Birth e x Status Mother
BCG Hepa Penta OPV IPV PCV MMR
B
1 2 3 1 2 3

D. Utilization of Health Services & Health Seeking Behavior

D.1. Do you utilize the health center? Yes ____ No ____
D.2. Reason:
______Dental ______Nutrition
______Family Planning ______Prenatal
______Illness ______Postnatal
D.3. First person consulted in times of illness:
______Physician ______BHW ______Others (Specify):
______Nurse ______Hilot _____________
______Midwife ______Herbularyo

V. ENVIRONMENTAL SANITATION DATA

1. SOURCES OF DRINKING WATER
____LMWD (public) ____Mineral water ____Water Pump
____LMWD (residential) ____Open dug well
2. METHODS OF STORAGE OF DRINKING WATER
____Covered container ____Uncovered container
3. METHODS OF WATER TREATMENT
____Boiling ____Water purifier
____Chlorination ____No treatment
4. METHODS OF DOMESTIC WATER WASTE DISPOSAL
____Blind drainage ____Open drainage
5. METHODS OF GARBAGE COLLECTION
____Covered receptacle ____Uncovered receptacle ____None

6. METHODS OF GARBAGE DISPOSAL

____ Burning ____ Open dumping
 ____Burying ____ Riverside dumping
7. METHODS OF EXCRETA DISPOSAL
Sanitary Unsanitary ____Others (Specify):
____ Flush ____ Ballot system ___________
____Water sealed ____Cat hole
____Pit privy ____ None
8. METHODS OF ANIMAL MANAGEMENT
Presence:
____Cats ____Pigs ____Others (Specify):
____Dogs ____ No Animal ___________
Method:
____Tied/Fenced ____Astray
9. METHODS OF BACKYARD GARDENING
____Fruit-bearing ____Vegatables
____Herbal ____Others (Specify):_______________

VI. COMMUNITY NEEDS AND PROBLEMS

A. Para ha oyp, ano an mga problema an iyo nakikit-an ha iyo barangay?

Parte Panglawas Diri Parte Panglawas

_____________ _____________
_____________ _____________
_____________ _____________

B. May maaram ba kamo nga mga organisasyon dinhi ha iyo barangay? Yes____ No____
If YES, Specify:__________________________________________________________
___________________________________________________________

C. Mayda ba miyembro ha iyo pamilya hin organisasyon?

Hin-o an Miyembro Ano nga Organisasyon

_____________ _____________
_____________ _____________
_____________ _____________

VII. TOPICS FOR HEALTH EDUCATION

Which subjects you want to learn in health education?

____Drug abuse ____Herbal Plants

____Family Planning ____Nutrition
____First Aid Measure ____Others (Specify):_________________________