COMMUNITY HEALTH ASSESSMENT FORM

Respondent: Kate Mahusay Age: 40 years old

Stage: Sex: Female
Relation to Head of the Family:None (If not the Head of the Family)

I. Family Data

A. Head of the family: Aldrin Mahusay Age: 46 years old

B. Name of Spouse: Kate Mahusay Age: 40 years old
C. Address: Sitio San Vicente Bulacao Cebu City Tel No.: None
D. Educational Attainment
Husband: Highschool Graduate
Wife: College

E. Length of Residency: 19 years

F. Ethnic Origin: Filipino
G. Family: Nuclear
Nuclear ( ✓ ) Extended ( )
H. Religion: Roman Catholic
I. No. of Children: 2
J. Members of the Household: 4

Name Age Sex Status Education Occupation

Aldrin Mahusay 46 years old MALE MARRIED HIGHSCHOOL GRADUATE Construction Worker
Kate Mahusay 40 years old FEMALE MARRIED COLLEGE House Wife
Jerome Mahusay 22 years old FEMALE SINGLE COLLEGE Student
Jr Mahusay 17 years old MALE SINGLE SENIOR HIGHSCHOOL Student

II. Socio Economic Data

A. Source of Income
Occupation: Construction worker

Husband: Aldrin Mahusay

Employed (✓) Unemployed ( ) Self–employed ( )

Monthly Income
Below ₱ 2,000 ( ) ₱ 2,000 - ₱ 5,000 (✓ )
₱ 5,001 - ₱ 8,000 ( ) more than ₱ 8,000 ( )

Wife: Kate Mahusay

Employed ( ) Unemployed ( ✓) Self–employed ()
Monthly Income
Below ₱ 2,000 ( ) ₱ 2,000 - ₱ 5,000 (✓ )
₱ 5,001 - ₱ 8,000 ( ) more than ₱ 8,000 ( )

B. Family Expenditures

1. Food
Below ₱ 50 ( ) ₱ 50 – 75 ( ) More than ₱ 70 (✓ )

2. Clothing number of times of buying

Once a year ( ) Twice (✓ ) Thrice a year ( )

3. Housing
Water (✓ ) Electricity (✓ ) Telephone ( )

4. Schooling
Public (✓ ) Private ( )

5. Others

III. Housing and Environmental Condition

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:
Plastic ( ) Clay jars ( )
Bottles ( ) Others:

D. Toilet Facilities
Sanitary:
Flush (✓) Pit privy ( ) Others:

Owned ( ✓) Shared ()
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 NONE

IV. Community Resources

A. Health and Other Facilities
Health center (✓ ) Barangay hall (✓ )
School (✓ ) Church (✓ )
Park ( ) Market (✓ )
Health center (✓ ) Private clinic ( )
Public hospital (✓ ) Private hospital ( )

B. Indigenous health workers

Trained “hilot ” ( ) BHW ()
“Herbularyo” (✓ ) 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 and egg (✓ ) Rice and sardines (✓ )
Rice and noodles (✓ ) Others:
 C. Presence of Nutritional Disorder
a. Goiter
Enlargement of the neck ( ) Dysphagia ( )
Hoarseness ( ) Others: NONE

b. Anemia ( ✓ )
Pallor ( ) Easy fatigability ( ) Body
weakness ( )

c. Vitamin A deficiency
Night blindness ( ) “Pilak sa mata” ( )
d. Others:

VI. Knowledge, Attitude and 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

Fever Colds

What do you do for this condition?

Self- medication ( ✓) Consultation ( )
Hospital ( ) Private clinics ( )
Nursing ( ) Others:
E. Others diseases
TB ( ) Leprosy ( )
Skin disease ( ) Hepatitis ()
Others NONE
F. Do you submit your children (0-12 months) for immunization?

Name of Child Birthday Immunization

BCG DPT OPV AM
Jerome Mahusay March 21, 1999 ✓ ✓ ✓ ✓
Jr. Mahusay January17, 2004 ✓ ✓ ✓ ✓
G. Do you practice family planning?
Yes ( ✓ ) No ( ) Method: IUD
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: Mark Jovan Teopiz. Jr.

Date: Sept 21,2021 Time: 5:00 PM