ADVENTIST MEDICAL CENTER COLLEGE

Brgy. San Miguel Iligan City

AY 2022-2023

SCHOOL OF NURSING
Need Assessment Survey Questionnaire

Barangay : ____________________________________ Purok/ Zone : ______ House Number : ______

Interviewer:______________________________________ Date Surveyed : _________________________

Direction: Please write your answer on the space provided or indicate a check ( √ ) sign on the space that
corresponds to your answer.

I. Family Structure, Characteristics, and Dynamics

1.1. Members of the household
Name Age Gender Civil Status Educational Attainment

1.2. Family members not residing in the household but contribute or affect family resource generation & use
Name Age Gender Civil Educational Position in
Status Attainment the Family

1.3. Type of family: ( ) nuclear ( ) extended ( ) blended ( ) dyad ( ) compound ( ) cohabiting

( ) single parent
1.4. Dominant family member/s in terms of decision making (especially on matters of health) and care-tending
_______________

II. Socio- economic and Cultural Characteristics

2.1. Monthly Income
Occupation Income of each
Type of work Place working member
Father
Mother
Children

2. 2. Monthly Budget. (Please rank according to the portion of the family monthly budget, with 1 as the
highest & 10 as the least.)
Necessities Rank Necessities Rank
Food Home maintenance
Clothing Recreation activities
Communication ( telephone bills/ load) Transportation expenses ( fare/ car fuel)
Education Vices
Electricity & water Savings
Health maintenance Others, specify
2. 3. Who makes decision about money and how it is spent: __________________________________
2.4. Religion_______________________________________________________________________
2.5. Length of residency_________________ 2. 6. Ethnic background: _______________________
2.7. Cultural beliefs and practices/ traditions that affect health :
III. Home/ Environmental Health and Sanitation
3.1. Housing
 3.1.1. Lot ownership : ( ) Owned ( ) Rented ( ) Others, pls. specify : ______________________
3.1.2. Home ownership: ( ) Owned ( ) Rented ( ) Others, pls. specify : ______________________
3.1.4. Construction materials used: ( ) Light ( ) Mixed ( ) Strong
3.1.5. Adequacy of living space for sleeping ______________________
3.1.6. Lighting facilities : ( ) Electricity ( ) Kerosene ( ) Others: specify
3.1.7. Ventilation: ( ) Excellent ( ) Very good ( ) Good ( ) Poor/ Needs improvement
3.1.8. Food storage : ( ) Refrigerator ( ) Others, pls. Specify : _____________________________
3.1.9. Sanitary condition : ( ) Excellent ( ) Very good ( ) Good ( ) Poor/ Needs
Improvement
3.2. Water Supply
3.2.1. Source : ( ) Level 1 ( Point source) protected well 250 meters away for 15-25 families.
( ) Level II ( Communal faucet system) not more than 25 meters away,1:4-6 households
( ) Level III ( Waterworks system) piped distribution for household taps.
3.2.2. Other types of drinking water : ( ) Processed bottled water ( ) Boiled water ( ) Others, pls.specify ___
3.2.3. Storage: ( ) covered container with faucet ( ) no- covered container ( ) no storage/ direct from pipe
3.3.Kitchen
3.3.1. Cooking facility: ( ) Electric stove ( ) Gas stove ( ) Firewood /Charcoal
3.3.2. Sanitary condition: ( ) Excellent ( ) Very good ( ) Good ( ) Poor/ Needs improvement
4. Drainage facility: ( ) Open drainage ( ) Blind drainage ( ) None
5. Waste Disposal
5.1. Refuse & garbage: ( ) Covered container ( ) Open container
5.2. Method of disposal: ( ) Hog feeding ( ) Open burning ( ) Open dumping
( ) Garbage collection ( ) Burial in pit ( ) Composting
( ) none ( ) Others, pls. specify: ______________________
6. Toilet
6.1. Type: ( ) without toilet ( ) open pit privy ( ) closed pit privy
( ) bored- hole latrine ( ) overhung latrine ( ) antipolo type
( ) water- sealed latrin ( ) flush type ( ) others, specify:
6.2. Distance from house: _____________________
6.3. Sanitary condition: ( ) Excellent ( ) Very good ( ) Good ( ) Poor/ Needs
improvement
7. Domestic animals:
Kind Numbers Place animals are kept

7.2. Sanitary condition, : ( ) Excellent ( ) Very good ( ) Good ( ) Poor/ Needs improvement
8. Presence of accident / fire hazards
( ) Beside the highway ( ) Under the coconut/any tree/s ( ) Pointed sharp objects
( ) Stair no hand rails ( ) Children (`1-10 yrs old) left alone in the house
( ) Poison and medicines improperly kept ( ) Others, specify
9. Establishment
9. 1 Food establishment: ( ) eatery ( ) bakeshop/ snack house ( ) others, specify
9.2. Non- food establishment: ( ) sari- sari store ( ) others, specify
10. Presence of breeding or resting sites of insects (mosquitoes, cockroaches’ etc,) rodents, vectors of diseases:
( ) Yes. Pls. specify _________________________________ ( ) None
11. The Community in General
10.1. General sanitary condition: ( ) Excellent ( ) Very good ( ) Good ( ) Poor/ Needs
improvement
10.2. Housing congestion: ( ) Yes ) No
10.3. Social/ Recreational facilities: If Yes, ( ) Basketball court ( ) Tennis court ( ) Others
specify ( ) None
10.4. Availability of health care services: ( ) health center ( ) birthing clinic, etc specify ( ) none
10.5. Distance from house to the nearest health care facility: ____________________________
10.6. Communication & transportation facilities available:
Communication: ( ) cellphone ( ) radio ( ) etc. specify
Transportation: ( ) motorcycle ( ) PUV ( ) etc, specify

IV. Health status

4.1. Heriditary disease/s: ( ) Hypertension ( ) Diabetes ( ) Others, specify__________
4.2. History of illness / Present illness ( pls. Specify)

Non-Communicable Maintenance Communicable Diseases Maintenance

Diseases medication/s medication/s
Cancer Avian Flu
Cataract Dengue
 Coronary Artery Disease Filariasis
Renal disease Gonorrhea
Diabetes type 1 HIV/AIDS
Diabetes type 2 Leprosy
Cataract Leptospirosis
Glaucoma Malaria
Hypertension Meningococcemia
Mental illness PTB
Obesity Rabies
Others, specify Syphilis
4.1.1. Non- communicable/Communicable and lifestyle diseases
4.1.2 .Communicable diseases

4.2. Usual health provider: ( ) Doctor ( ) Nurse ( ) Midwife ( ) Others, specify

4.3. Source of health information: ( ) TV ( ) Internet ( ) Radio ( ) Others, specify

V. Nutritional assessment (esp. for vulnerable or at risk member)

5.1. Weight & height or BMI (wt. in kg divided by ht. in meters2)
Family Members Weight Height BMI Interpretation

5.2. Dietary history specifying quality and quantity of food / nutrients intake per day ( Usual food eaten):
( ) Rice ( ) Vegetables ( ) Fish ( ) Meat ( ) Chicken
5.3. Eating / feeding habits/ practices: ( ) 3 meals ( ) 2 meals ( ) 1 meal
5.4. Between meals: ( ) junk foods ( ) others, specify:
5.5. Amount of water intake per day (no. of glasses )

VI. Lifestyle
6.1. Diet ( ) Herbivorous ( ) Carnivorous ( ) Omnivorous ( ) Others, ( ) specify:
6.2. Rest & sleep:
6.2.1 Nap after lunch: ( )Yes ( ) No
6.2.2 Number of hours of sleep at night: ( ) Father ( ) Mother ( ) Children: 1.______ 2. _______
6.3. Exercise : ( ) Yes, then how often? _______ days /week ( ) No
6.4. Cigarette Smoking: ( ) Yes, then how many sticks? _______ per day/ week ( ) No
6. 5. Alcoholic Drinking: ( ) Yes, then how many bottle/s per day? ____________ ( ) No
6. 6. Use of any prohibited drugs/ substance: ( ) Yes ( ) No
If yes, pls. specify__________________________ How often?___________ How long?__________

VII. Family Planning ( 15 – 49 years old only )

7.1. How many children do you want? ( ) 1- 3 ( ) 4 & above
7.2. What is your plan for the interval of pregnancy? ( ) 2 years ( ) 2 years above
7.3. Did you receive family planning and responsible parenthood lectures prior to marriage? ( ) Yes ( ) No
7.4. From where did you get the information? ( ) Midwife ( ) BHW ( ) Nurse
( ) Doctor ( ) Neighbour ( ) Others, specify
7.5. Are you practicing family planning? ( ) Yes ( ) No
7.6. If yes, where do you get the supply ( ) BHS ( ) Hospital ( ) Others, specify
7.7. What family planning method are you using?
Natural Methods Modern Family Planning Permanent Methods
Methods
Basal body temperature Cervical cap Bilateral tubal ligation
Lactation amenorrhea method Condom Vasectomy
Standard days method Diaphragm
Symptothermal method Depo Provera
The two day method Intrauterine device (IUD)
The ovulation method Norplant implant
Pills
7. 8. Are you satisfied with the family planning method that you used? ( ) Yes ( ) No
7.9. If no, what is the reason/ reasons? ( ) no approval from the spouse ( ) religion
( ) side effects of the FB method ( ) sickness
7.10. Did your husband participate/ cooperate in the family planning? ( ) Yes ( ) No, reason
7.11. Do you plan to stop using the family planning method? ( ) Yes ( ) No, state the reason

VIII. Maternal & Child Health

8.1. Prenatal ( pregnant )
8.1.1. Menstrual History:
Age Interval Duration Abnormalities
 Menarche
Date of Last Menstruation Period
(LMP)
8.1.2. Obstetrical History:
Gravida Para Term Preterm Abortion Living Multiple
Spontaneous Induced

8.1.3. BirthHistory:
No. Month/ Infant Weight Age of Hours in Type of Place of Anesthesia
Year Sex at Birth Gestation in Labor Delivery Delivery Received
Weeks

8.1.4. Past Health History / Present Illness

Date of Diagnosis Medications
consultation
1st 3 months of pregnancy
4- 6 months of pregnancy
7- 9 months of pregnancy
8.1. 5. Immunization Received
Tetanus toxoid vaccine Date given
TT1
TT2
TT3
TT4
TT5
If not able to receive Tetanus toxoid, please indicate reason:______________________________
8.1.6. Micronutrient Supplementation
Iron and Folate 60mg/400mcg once a day for 6 months ( ) Yes ( ) No, reason:
Vit. A 10,000 IU twice a week from 4th month of pregnancy ( ) Yes ( ) No, eason
Iodine 200mg once during pregnancy ( ) Yes ( ) No, reason:
8.1.8. Prenatal Check- up /Consultation at least 4 visits throughout the course of pregnancy:
( ) once in first trimester ( ) once in 2nd trimester ( ) twice in third trimester
( ) 5 visits or more ( ) others, specify ( ) None, State the reason:
8.1.9. Dental Check- up: ( ) Yes ( ) No, State the reason:
8.1.10. Plan for Breastfeeding: ( ) Yes ( ) No, State the reason:
8.1.11. Diagnostic Test Done
Diagnostic Tests Date Findings/ result
CBC
Blood typing
Hbs Ag
Urinalysis
Blood sugar screening
Screening for STD
Cervical cancer screening
8.1.12. Nutrition
What are the kinds of foods you eat regularly within a week?
Go foods: ( ) Rice ( ) Mais ( ) Others, specify________________
Grow foods: ( ) Fish ( ) Meat ( ) Dilis ( ) Others, specify
Glow foods: ( ) Squash ( ) Malunggay ( ) Alugbate ( ) Camote tops
( ) Kangkong ( ) Papaya ( ) Others, specify __________________
8.2. Postpartum ( 1 day- 1 month postpartum)
8.2.1.Obstetrical History
Gravida____ Para_____ Term_____ Preterm____ Abortion____ Living_____ Multiple_____
Date of Delivery: _______________________ Place of delivery__________________________
Type of Delivery: _______________________ Duration of labor_________________________
8.2.2. Postpartum consultation:
When was your postpartum visit? ( ) within 72 hours/ 3 days postpartum ( ) 7th day postpartum
( ) others, specify _____________________________
Where did you go for consultation? ( ) RHU ( ) hospital ( ) others, specify
Whom did you consult? ( ) midwife ( ) nurse ( ) doctor
8.2.3. Micronutrient supplementation: ( ) Iron & Folate (60mg/400mcg) once a day for 3 months
( ) Vitamin A 200,000 IU within 4 weeks after deliver
( ) None, state reason
8.2.4. Newborn Feeding: ( ) Breastfeeding ( ) Bottle feeding ( ) Mixed
8.2.5. Feeding Positions: ( ) cradle hold ( ) cross cradle hold ( ) side lying ( ) football hold ( ) saddle hold
 8.2.6. Breastfeeding Attachment: ( ) proper ( ) improper

8.3. Pediatric Assessment ( Newborn to school age)

Birth Date of Type of Hours in Birth Birth Place Actual
rank birth delivery labor wt. attendant delivered Ht. Wt. AC

8.3.4. Newborn Screening ( children 0- 2 months old): ( ) Yes ( ) No

8.3.5. Child’s Feeding Practices:
( ) Exclusive Breastfeeding ( first 6 months ) ( ) Extended Breastfeeding up to 2 years
( ) Predominant Breastfeeding ( ) Bottle Feeding
( ) Complimentary Feeding ( ) Solid foods ( ) Others, specify; __________
8.3. 6. Micronutrients Supplementation:
Vitamin A : ( ) Yes ( ) None, state reason
Iron for low birth weight infant (2- 59 months old ): ( ) Yes ( ) None, reason
8.3.7. Deworming every 6 months ( Children 1- 12 years old) ( ) Yes ( ) None
8.3.8. Imunization ( Children Age 0-15 months old) Pls. include all children ( use extra paper if needed)
BCG OPV3 Pentavalent 3 PCV 3
Hepa B at birth IPV PCV 1 Measle vaccine (AMV1)
OPV1 Pentavalent 1 PCV 2 MMR
OPV2 Pentavalent 2

8.3.9. History of Illness/ Present illnes

Anemia Malaria Primary Complex (TB)
Diarrhea Malnutrition Polio
Dengue Measles Rubella ( German measles)
Diphtheria Meningitis Sepsis
Ear Infection Mumps Severe Dehydration
Hepatitis Pertussis (Whooping Cough) Tetanus/ Tetanus Neonatorum
Influenza Pneumonia Others, specify
8.3.10. Usual health provider: ( ) Doctor ( ) Nurse ( ) Midwife ( ) Others,
specify

IX. Adolescent Reproductive Health

9.1. Family members who married at the age of 18 and below: ( ) Yes ( ) None
9.2. Family members who got pregnant at the age of 18 and below: ( ) Yes ( ) None
9.3. Family member who has experienced miscarriage: ( ) None ( ) Yes, reason
If yes, at what age? _______________________
9.4. Discussion in the family on matters regarding sexuality: ( ) Yes ( ) No

Thank You and God Bless!

Prepared by: Approved by:

Armenia Grace M. Maghanoy, RN, MAN Roselyn S. Pacardo, RM, RN, MM, MAN
Community Extension Coordinator, SON Dean, School of Nursing

Noted by:

Ruby Socorro A. Recopelacion, MAS

Community Extension Director