COMMUNITY HEALTH ASSESSMENT FORM

Respondent: ___________________________ Age: ________

Relation to Head: ______________________ Sex: ________

I. Family Data
A. Head of the Family: _______________________ Age: _______
B. Name of Spouse: _________________________ Age: _______
C. Address: ___________________________ Tel. No. __________
D. Educational Attainment: _________________________
i. Husband: _______________________________
ii. Wife: ___________________________________
E. Length of Residency: _____________________________
F. Ethnic Origin: ___________________________________
G. Family
i. Nuclear ( ) Extended ( )
H. Religion: _______________________
I. No. Of Children: _________________
J. Members of the Household: __________
NAME AGE SEX STATUS EDUCATION OCCUPATION

II. Socio Economic Data

A. Source of Income
Occupation:
Husband: _____________________________
Wife: _________________________________
Employed ( ) Unemployed ( )
Self-employed ( )
Monthly Income:
Below 2,000 ( ) 2,000-5,000 ( )
More than 70 ( )
B. Family Expenditures
1. Food
Below 50 ( ) 50 – 75 ( )
More than 75 ( )
2. Clothing: number of times of buying
Once a year ( ) Twice ( )
Thrice ( )
3. Housing
Water ( ) Electricity ( )
Telephone ( )
4. Schooling
Public ( ) Private ( )

III. Housing and Environmental Condition

A. Home
Type
Concrete ( ) Mixed ( )
Wood ( ) Makeshift ( )
 Ventilation
Poor ( ) Good ( )
Lighting
Adequate ( ) Inadequate ( )
Surroundings
Clean ( ) Dirty ( )
B. Source of Water Supply
Artesian Well ( ) Deep Well ( )
Nawasa ( )
C. Storage of Drinking Water
Refrigerated ( ) Covered ( )
Uncovered ( )
D. Toilet Facilities
Sanitary:
Flush ( ) Pit Privy ( )
Unsanitary:
Ballot System ( )
E. Garbage Disposal
Collection ( ) Burning ( )
Burying ( ) Open Dumping ( )
Garbage Can ( )
F. Food Storage
Covered ( ) Uncovered ( )
Refrigerated ( )
G. Presence of Animals
Dogs ( ) Cats ( )
Pigs ( )
H. Backyard Gardening
Vegetable ( ) Herbal ( )
Fruit bearing ( )
IV. Community Resources
I. Health and Other Facilities
Health Center ( ) Barangay Hall ( )
School ( ) Church ( )
Park ( ) Market ( )
J. Indigenous Health Workers
Trained Hilot ( ) BHW ( )
Herbularyo ( ) Untrained Hilot ( )
K. Sources of Health Funds
Government ( ) Private ( )
NGO’S/PO’S ( )
V. Nutrition
A. Food Preferences
Fish ( ) Fruits/Vegetables ( )
Meat ( ) Mixed ( )
B. Common Fare
Rice & Egg ( ) Rice & Sardines ( )
Rice & Noodles ( )
VI. Knowledge, Attitude and Practice
A. Do you utilize the health center? Yes ( ) No ( )
If no, why?
B. Reason:
Illness ( ) Prenatal ( )
Family Planning ( ) Postnatal ( )
Dental ( ) Nutrition ( )
C. First person consulted in times of illness:
M.D. ( ) Nurse ( )
Midwife ( ) “Hilot” ( )
“Herbularyo” ( ) BHW ( )
D. Usual illness in the family
_____________________________ _____________________________
_____________________________ _____________________________
_____________________________ _____________________________
What do you do for this condition?
Self-medication ( ) Consultation ( )
Hospital ( ) Private ( )
Nursing ( )
E. Do you submit your children ( 0-12 months ) for immunization?
NAME OF CHILD BIRTHDAY IMMUNIZATION
BCG DPT OPV M

F. Do you practice family planning? Yes ( ) No ( )

Method:
If no, why?
G. Method of Infant Feeding:
Breast ( ) Bottle ( )
Mixed ( )
H. Subjects you want to learn in health education:
Drugs ( ) Nutrition ( )
Family Planning ( ) Herbal Plants ( )
First Aid Measure ( )

Interviewed by: ___________________________ Date: ___________ Time:

_________