Professional Documents
Culture Documents
Interview Questionnaire
Interview Questionnaire
Interview Questionnaire
SCHOOL OF MIDWIFERY
2600 Legarda St. Sampaloc, Metro Manila
Telephone No. 87347371
www.arellano.edu.ph
INTERVIEW QUESTIONNAIRE
INITIAL DATA FOR FAMILY ASSESSMENT
PART I. Identification Information
Date:______________
Name of Head of the Family:______________________________________________________
Address: House No.:___________, Street:___________________________________________
Municipal/City:_____________________________________________________________________
Religion:_____________
No. Name Relation Gender Birth Age Civil Highest Occupation Employment
to head date Statu Education Status
s Completed
1.(Head
of the
Family
2.
Spouse
3.
Eldest
child
4.
5.
6.
7.
8.
9.
10.
How much of your income are you spending: (Please use percentage, for each item, a total of 100%)
Food __________%
Clothing________%
Education_______%
Health__________%
Transportation____%
Medication_______%
Leisure_________%
Others__________%
________________
Total___________%
Home Ownership:
[ ] owned [ ] shared [ ]rental
Housing:
Housing Structure:
[ ] concrete (strong material) [ ] mixed (combination of wood and concrete)
[ ] light (wood, lumber)
Ventilation:
[ ] well ventilated [ ] poorly ventilated
Lighting Facilities:
[ ] electric bulb [ ] used of kerosene lamp [ ] others________
Sources of Electricity:
[ ] owned [ ] shared
ARELLANO UNIVERSITY
SCHOOL OF MIDWIFERY
2600 Legarda St. Sampaloc, Metro Manila
Telephone No. 87347371
www.arellano.edu.ph
Toilet Facility:
Type of Latrine:
[ ] water-sealed [ ] flush-type [ ] open pit-hole privy
[ ] over-hung lantrine [ ] antipolo-type [ ] closed pit-hole privy
Location of Toilet:
[ ] inside the house [ ] outside the house
Ownership of Toilet:
[ ] owned [ ] shared [ ] public toilet
Status of Electricity:
[ ] owned [ ] shared
Garbage Disposal:
[ ] thrown/open dumping [ ] collected (frequency)_________ X a week
[ ] open burning [ ] composting
[ ] burial pit
Presence of Pollution:
[ ] air [ ] water [ ] land [ ] noise
Kind of neighborhood:
[ ] slum [ ] congested [ ] subdivision
Drainage:
[ ] close drainage [ ] open drainage [ ] none
Where does domestic manure (pigs, ducks, chicken) are being dispose:
[ ] open dumping [ ] recycled [ ] thrown [ ] others
Water Supply:
Source of Drinking Water:
[ ] Maynilad [ ] deep well [ ] artesian well [ ] Water station (refilling)
Housing Congestion:
[ ] good/adequate [ ] poor/congested [ ] disorderly
Recreational Facilities:
[ ] Parks [ ] playground
[ ] Amusement Center [ ] Sports Facilities
Chronic Illness
[ ] Diabetes [ ] Tuberculosis [ ] Heart Disease
[ ] Hypertension [ ] Hepatitis B/C [ ] Cancer
Immunization against:
[ ] Influenza [ ] Covid 19
[ ] Cervical cancer/HPV
[ ] H1N1
Vices
[ ] smoking ___________(note number of sticks per day)
[ ] alcoholism _________(note number of bottles per day)
[ ] prohibited drugs_______(specify)
For Females:
Do you conduct or submit yourself for the following procedure:
[ ] Monthly self breast examination
[ ] yearly Pap Smear
[ ] annual physical examination
[ ] others
For Males:
Do you conduct or submit yourself for the following procedure:
[ ] Testicular Examination
[ ] annual physical examination
ARELLANO UNIVERSITY
SCHOOL OF MIDWIFERY
2600 Legarda St. Sampaloc, Metro Manila
Telephone No. 87347371
www.arellano.edu.ph
[ ] others
Nutritional Assessment
Sources of food:
[ ] self-produced [ ] from the market
Pre-Natal Check-Up:
[ ] LMP_____ [ ] EDC______ [ ] AOG_____
Consultation:
[ ] every month [ ] twice a month [ ] weekly [ ] none at all
Place of Consultation
[ ] Health Center [ ] Government Hospital
[ ] Lying In Clinic [ ] Private Hospital
Natural Method
[ ] Withdrawal [ ] Abstinence [ ] Lactated Amenorrhea Method
[ ] Calendar Method [ ] Billing Method
ARELLANO UNIVERSITY
SCHOOL OF MIDWIFERY
2600 Legarda St. Sampaloc, Metro Manila
Telephone No. 87347371
www.arellano.edu.ph
Immunization:
Immunization with Children 0-12 months
Name of Child Age Immunization Received (Please Remarks/Evaluation
Check) Complete/Incomplete
[ ] BCG [ ]DPT (3)
[ ] OPV (3) [ ] Measles
[ ] Hepatitis B (3)
[ ] BCG [ ]DPT (3)
[ ] OPV (3) [ ] Measles
[ ] Hepatitis B (3)
[ ] BCG [ ]DPT (3)
[ ] OPV (3) [ ] Measles
[ ] Hepatitis B (3)
[ ] BCG [ ]DPT (3)
[ ] OPV (3) [ ] Measles
[ ] Hepatitis B (3)
[ ] BCG [ ]DPT (3)
[ ] OPV (3) [ ] Measles
[ ] Hepatitis B (3)
JPReyes 2023