Davao Doctors College

General Malvar St., Davao City

Nursing Program

COMMUNITY HEALTH SURVEY TOOL

I. Household Members
NAME AGE SEX RELIGION RELATION BIRTH CIVIL HIGHEST OCCUPATION DAILY / IMMUNIZATION LITERACY REMARKS
TO THE DATE STATUS EDUCATION MONTHLY STATUS STATUS
HEAD ATTAINMENT SALARY
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Legend: Put * after the surname of deceased individual. Write the cause and place of death under the remarks column. In addition, note down any health abnormalities
of the above individuals indicating in terms of prenatal, post-partum, mental retarded, morbid case (specify present illness), malnourished, and overweight. Indicate
the place of birth for neonates. Mark (X) if not immunized, C for complete, and (?) if not known. Place “OS” if out of school then write the reason under the column
remarks. Use the term employed and unemployed for their occupational status. Indicate the literacy status whether literate (can read and write) or illiterate.

II. Length of Residency:

III. Type of Family: ( ) NUCLEAR FAMILY ( ) EXTENDED FAMILY ( ) SINGLE PARENT ( ) DYAD FAMILY ( ) COHABITATION

IV. Home Environment: ( ) House & Lot; Owned ( ) House & Lot; Rented ( ) Others: Specify:

V. Type of House: ( ) CONCRETE ( ) WOOD ( ) MIXED ( ) MAKESHIFT ( ) Others: Specify:

 Davao Doctors College
General Malvar St., Davao City
Nursing Program

VI. Ethnicity: ( ) Bisaya ( ) Ilocano ( ) Mandaya ( ) Manubo ( ) Mansaka ( ) Tagacaulo ( ) Calagan ( ) Bagobo ( ) B’laan ( ) T’boli ( ) Others:

VII. Language/ Dialect Spoken: ( ) Davaoeño ( ) Agta ( ) Manobo ( ) Filipino ( ) Cebuano ( ) English ( ) Kamayo ( ) T’boli ( ) Tagabawa ( ) Others:

VIII. Medium of Communication: ( ) Cellphone ( ) Landline ( ) Radio ( ) Television ( ) Others: Specify:

IX. Transportation Facility: ( ) Pedicab/Bicycle ( ) Motorbike ( ) Tricycle ( ) Jeep ( ) Bus ( ) Taxi ( ) Private Car ( ) Others: Specify:

X. Water Source: ( ) WATER PIPE ( ) POSO NEGRO ( ) DEEP WELL ( ) RAINWATER ( ) Others: Specify:

XI. Waste Disposal: ( ) COMPOST PIT ( ) CENRO ( ) TRASH BIN ( ) Others: Specify:

XII. Comfort Room: ( ) WATER SEALED ( ) CLOSED PIT ( ) OPEN PIT ( ) Others: Specify:

XIII. Health Practice: ( ) Hilot ( ) Quack Doctor ( ) Health Center ( ) Doctor/Hospital ( ) Self-Medicating ( ) Herbal Meds ( ) Others: Specify:

XIV. Accidental Hazards: ( ) None ( ) Broken Stairs ( ) Poisons ( ) Pointed/Sharp objects ( ) Fire Hazards ( ) Fall Hazards ( ) Others: Specify:

XV. What are your health beliefs and practices?

XVI. What are your concepts and understanding about health and illness?

XVII. What is the importance of health?

XVIII. What are the common issues and problems in your community?

XIX. What are the usual activities of the families/ recreational activities?
Davao Doctors College
General Malvar St., Davao City
Nursing Program