Republic of the Philippines

Family no.____ H.C.____ Metro Manila

No. _____ HEALTH OPERATION CENTER

COMMUNITY SURVEY FORM Date Surveyed____________

Length of residency_______
Father ____________________________________ Religion____________ Place of origin __________
Last First M.I. Length of residency ______
Mother_____________________________________ Religion____________ Place of origin __________
District No.:__________
Address______________________________________ Purok No.______ Brgy No._____ Zone No._____
Other members of household: ________
Data on Family: No. of children Living______ Dead_______ Abortion_______

Immunization for last 5 yrs. Cases

Name Dat Ag Se Civil Relationshi Educatio Occupatio Incom BC DP OP Measle Tetanu AP PP TB FP Mentall Malnourishe Drug Other
s e of e x Statu p n n e G T V s s y d abuse s
birt s to the Head Toxoid Retarte r
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Family
HOME
A) Type of building (uri ng bahay) WATER SUPPLY OTHER INFORMATION RELATED TO FAMILY HEALTH
Strong ( ) Light ( ) A.)Source(pinanggagalingan) (Iba pang impormasyon kaugnay sa kalusugan ng pamilya)
(matibay) (Magaan) Private(Pribado) ( ) A.)Food storage(Pag-iimbak ng pagkain)
Public(Publiko) ( ) Covered(Nakatakip ( )
Mixed ( ) Makeshift ( ) 1.)Pipe(Tubo) ( ) Uncovered(Walang takip) ( )
(Magkahalo) (Pangsamantala) 2.)Hose(hos) ( ) B.)Type of infant feeding(0-2yrs) ( )
3.)Pail(Timba) ( ) (Uri ng pagpapakain)
B) General Sanitary Condition 4.)Other(Iba pa) ( ) Breastfeeding(pagpapasuso) ( )
(kalahating lagay ng kalinisan) Aritificial(Artipisyal/do natural)( )
Good ( ) Light ( ) Poor( ) B.)Drinking water storage C.)Type of Artificial Feeding
(Mahusay) (Katamtaman) (Di mabuti) (Pag-iimbak ng tubig) Condensed(Malapot) ( )
Covered)Nakatakip ( ) Evaporated(Malabnaw) ( )
C) Excretal Disposal ( Pagtatapon ng dumi) Uncovered(walang takip) ( ) Powdered(Pulbos) ( )
Sewage (A;kantariliya) ( ) 1.)Can(Lata) ( ) D.)Food supplements given to babies
Septic Tank ( ) 2.)Drum(Dram) ( ) (Karagdagang pagkain na binibigay sa sanggol)
Water sealed ( ) 3.)Bottle(Bote) ( ) Plain(Lugar) ( )
Public Comfort Room (palikuran) ( ) 4.)Faucet(Gripo) ( ) Mashed yellow fruites and vegetables ( )
Others, Specify (Iba pa, tukuyin) ( ) 5.)Others(Iba pa) ( ) (Dilaw na prutas at gulay) ( )
Egg(Itlog) ( )
D) Backyard Gardening (Halaman sa likod ng bahay GARBAGE DISPOSAL Flake fish,meat,chicken ( )
Vegatable (Gulay) ( ) A.)Method of Disposal (Manipis na piraso ng isda,karne,manok)( )
Ornamental(Palamuti/dekorasyon)( ) (Pagtatapong ng Basura) FAMILY PLANNING
Fruit tree (Punong namumunga)( ) DPS collection(pangongolekta ng DPS) ( ) Acceptor ( )
Others (Iba pa) ( ) Burning(Pagsunog) ( )
None (Wala na) ( ) Dumping(pagtatambak) ( )
What method? _______________
Burying(Pagbabaon) ( ) Non Acceptor ( )
COMMUNICABLE DISEASE Recycling ( ) Why? _________________
No. of TB cases ________ Others(Iba pa) ( ) Source of information of FP:
No. of Leprosy ________ HC ( ) Mass media ( )
Under treatment ( ) DENTAL SOURCE
Where?_______________ A.)Health Center ( )
Hospital ( ) Others,specify: ( )
Not under treatment ( ) B.)Hospital ( ) Neighbor ( ) ______________
SOURCE OF HEALTHCARE(PAGAMUTAN) C.)Private ( ) SURVEYED BY:_______________________
A.) Health Center ( ) D.)Industrial Dentist ( ) (NAME)
B.) Hospital ( ) E.)Others ( ) ______________________
C.) Private ( )
D.) Others ( )
(DESIGNATION)