Christ the King College

COLLEGE OF NURSING

COMMUNITY HEALTH SURVEY

RESPONDENT’S NAME: CAPEDING, ADOLFO NHTS_PR ID No.:

Brgy/Purok : TRINIDAD- 2 HH No. : 506 CCT NON-NHTS:
DATE: 12/14/2022 PHIC ID No.: NON-CCT 4PS

I.SOCIO-ECOMNOMIC-DEMOGRAPHIC-CULTURE DATA
A.FAMILY STRUCTURE & SYSTEM
Education
Approx.
Sex al Source of
Name of Family Members Position Age CS Religion Nationality Monthly
/LGBT Attainme Income
Income
nt
HUSBAND 73 M M ROMAN HIGSCHO FILIPINO PENSION 22K
ADOLFO CAPEDING CATHOLIC OL LEVEL
APOLONIA CAPEDING WIFE 70 F M ROMAN COLLEGE FILIPINO PENSION 19K
CATHOLIC GRAD.

a. Family size: 2

b. Family Structure Type ( )

Extended: Nuclear : Others, specify ___________

c. Decision making in the family
c.1 Finances c.2 Health c.3 Education c.4 Community Involvement
Mother
Father
Children
d. Describe the communication process among the members.
______________________________________________________________________________________
______________________________________________________________________________________
e. Land and House Ownership
Owned: Rented: Owned by Parents: Squatters:
f. Type of Housing
Concrete: Light Materials: Combination:
g. Condition within the Home
Well ventilated : Adequate living space :
Clean: How many rooms? 2
Dirty: Presence of hazards, identify:_______________________________________
Crowding:

1
B.SOCIO-ECONOMIC CHARACTERISTICS
a. Type of Community: Rural Urban
b. Membership in Civic/Community Organizations
Member: Position/Role: BRGY. COUNCILOR Name of Organization: BRGY. COUNCIL
Non-member:
c. Describe the involvement of the family in Community Organizations:
“Pagtuman san pagkinahanglanon san barangay ngan maimplementar sin tadong ngan sadang”
d. Values being uphold by the family among the members
“Pagrosaryo kada kulop” “ Dudrungan nga pangaon namon nga mag asawa”
e. Beliefs and Practices
HEALTH FAMILY MANAGEMENT
Beliefs Practices Beliefs Practices
Insulin Plant “Ginhuhgasan katima hugas
sin maupay pwede mo siya
kisamon”
Ashitaba “Ginhuhgasan katima hugas
sin maupay pwede mo siya
kisamon”

C. POLITICAL
II. HEALTH
A. Immunization Status (Family with 0-59 mos.►start from eldest)
Where the Vaccine Received
Date of
Name of Child Age Immunization
Birth BCG DPT1,DPT2,DPT3 OPV Measles Others
was received

B. for Family with 0-11mos., indicate date when child becomes fully immunized
Month ______ Day _______ Year _______

C. for Family with 12-59mos., indicate date the child was given Vit. A
Month ______ Day _______ Year _______

D. Who is consulted in case somebody in the family is sick?

Doctor Midwife Trained Hilot Quack Doctor
Nurse BHW Self-medication done

E. How often do you go to the RHU or BHS for medical check-up?

Monthly Once every 6mos. Once a year
Every 2mos. Only when sick Reason:______________________________
Once in a quarter Never ▪Guide for the interviewer
1. Health Worker Factor
2. Lack if nearby Health facilities
3. House is very far from facilities
4. Socioeconomic factors

2
F. Enumerate common causes of sickness in the family, (Morbidity) in the past year.

TB: Mental Disorder Cardiovascular Disease PWDS

Malaria Hypertension Cancer Others Specify:_______________
Schistosomiasis Diabetes Cataract
G. Any heredofamilial disease? Specify.
ASTHMA

H. If a member of the family died in the past year, what was the common cause of death? (Mortality) Specify.
HILARIA FERREZ (aunt) cause of death- Old Age

I. For a family with 0-59 mos. old child, who attended the delivery of the mother?
Doctor Midwife Untrained Hilot (TBA)
Nurse Trained Hilot
J. Does the mother visit RHU or BHS for prenatal check-up?
YES/NO: SPECIFY WHERE:
LMP: EDC: AOG: BLOOD TYPE:

K. In most of her deliveries, where does the mother deliver her baby?
Hospital Date delivered: ___________________
Home 0-42 days: _______________________
Maternity Clinic
L. Tetanus Toxoid Vaccination of Woman of reproductive age (15-49y.o)
For mother/wife Total Tetanus Toxoid Status
Name Age CS
Pregnant? Not pregnant? Pregnancy TT1 TT TT3 TT TT
Want to add
Yes children?
No Yes
No

Do you think you are pregnant?

Yes
No
if unsure, advise to visit the RHU

M. Family planning practice of the couple

Acceptor Non Acceptor
FP Method Used Satisfied with Method
Pills Yes
IUD
DMPA No
Condom
BTL
Vasectomy
Implanon
Natural FP
LAM
Withdrawal
Calendar

Others:

N. Nutrition Status (children 0-59mos. old)

3
 Name Age Birthday Date weighed Actual Weight Status

O. Age when supplemental food was introduced. (Families with 0-2y.o.)

Specify ______________________
P. Type/kind of supplemental feeding (Families with 0-2 yr.)
Specify ______________________
Q. Method of Feeding (0-2 y.o.)
Breastfeeding Bottle feeding Mixed
R. If not BF, Specify reason
______________________________________________________________________________________
______________________________________________________________________________________
S. Children aging 1-4y.o., taking Vitamin Supplements?
Yes No

Date Given Name of Vitamin Where

III.ENVIRONMENTAL SANITATION DATA

A.DRINKING WATER
a. Water supply or source of drinking water (check the box)
Protected well Open dug wells (level 1)
Developed Spring (level 1) Unimproved Springs (level 1)
Communal Faucet (level 2) Individual House Connection
(level 3)
Tank (level 2)

b. Container of drinking water (check box)

Covered containers uncovered containers

c. If open dug well/unimproved springs, do you treat your water?

Yes No
What method of treatment? Chlorination Boiling

4
 B.EXCRETE DISPOSAL
With toilet Unapproved Type
Approved Type Antipolo Type
Pit Latrines Cathole
Pour flush toilet
WST/Flush type
Without toilet
C.SEWAGE DISPOSAL
Open drainage Blind Drainage
D.GARBAGE DISPOSAL
Burning Incineration Dumping in Land
Burying Placed in compost pit Dumping in river banks/seashore
E.FOOD STORAGE
Covered plated Covered plastic or food container (Tupperware)
Cabinets Refrigerator
F.GARDENS
Herbal Fruits
Flower Vegetables
G.AIR POLLUTION
Industrial plants/factories in the Barangay
Presence of cars/automobiles which emit gas/fumes
Smoker in the family
H.RECREATIONAL FACILITIES
Playground
Theater
Others, specify ____________________________
I.PRESENCE OF HEALTH HAZARDS IN THE COMMUNITY
None
Yes, specify ___________ ____________________________
J.PRESENCE OF INSECTS/RODENTS
None
Yes, specify ____________________________
K.PRESENCE OF STRAY ANIMALS
None
Yes, specify DOG Tied: Fenced

IV.COMMUNITY NEEDS AND PROBLEMS AS PERCIEVED BY THE FAMILY/SUGGESTION TO SOLVE THE ROBLEM

NEED / PROBLEM SUGGESTIONS

A. Community Leaders “Waray problema sa ira, maupay man makitungo”

B. Health Service “Nahahatag man an amon kinahanglan nga bulong pag

napakadto kami sa health center”
C. Source of Income -----

D. Peace and Order “Didi sa amon waray ak mayayakan sa pagpapatupad

E. Relationship of the Community People
F. Involvement in Community Activities
G. Infrastructure
san tama nga peace and orer”
‘ Maupay, may respeto an tawo ngan amon mga
hirigpid dinhi”
“ Pagmayada kami oras o libre nga oras nakikiusa
gihapon kami san amon mga hirigpid”
-----

H. Education “ An edukasyon importante, waray man kami nakikita

nga problema didi san kabataan”

●Thank you for your cooperation●

5
6