Community Diagnosis

Katito Sub-County Hospital

STUDENT NAME ………………………………DATE…………..

SECTION A: SOCIO-DEMOGRAPHIC
8. Relationship to H/H Head
1. What is the name of the village? Head
Spouse
Child
2. Name of the respondent. House help
Other children by relation
Others
3. Denomination 9. Education of the respondent
Catholic College complete
SDA College incomplete
ACK Secondary complete
Pentecost Secondary incomplete
Muslim Primary complete
Pagan Primary incomplete
4. Age of the respondents None
10. What is the Occupation of the
respondent
5. Do you have Children? Casual laborer
Yes Employed
No Self Employed
6. Sex of the respondent Farmer
Male Housewife
Female Student
7. Marital status 11. What is your main source of income
Married ( monogamy) Farming
Married ( polygamy) Small Business
Widow (er) Mega Business
Separated/ Divorced Salaried
Single None
 Condom
SECTION B: MATERNAL AND N/A
b. If No, what is hindering you from
CHILD INFORMATION using family planning methods?
12. How many children do you have? Spouse
0 Fear
1-3 Distance
4-7 Culture
8+ Religion
13. How old is the last born? [ ] N/A
14. If the child is less than 1 year, what is
the status of the child’s immunization?
Up to date SECTION C: SANITATION
Fully 18. (Observe)Is there a dish rack for
Dropped utensils?
N/A Yes
15. If the child is <5 years, when was the No
child lastly taken for growth 19. Where do you dispose solid waste?
monitoring? Toilet
Last week Bush
Last month
Shamba
Never
Bin
N/A
16. In your last delivery, where did you give
20. I. Where do you go for calls of nature?
birth?
Home Toilet
Hospital Bush
Roadside Shamba
Other II. If there is a toilet, Observe:
17. Have you heard of family planning? a. Is there a hand washing facility,
Yes nearby?
No Yes
If Yes, are you in family planning No
method? N/A
Yes b. Is there footsteps showing that
they are using that toilet.
No Yes
N/A No
N/A
a. If Yes, which method? c. Is it a good structured
Injectable
toilet(shelter, privacy,
Pills
ventilation)
Implant
Yes
IUCD
No
 N/A
d. What is the distance of the SECTION E: SOCIALECONOMIC
toilet from the household?
INFORMATION
Long
30. Do you belong to any chama?
Short
Yes
No
SECTION D: NUTRITION AND If Yes, what’s its main benefit?
DIET Social support
21. How many times does your family eat Psycho support
Financial support
when at home…………………….
Spiritual nourishment
22. Do you have any kind of food stuff in
Education
stock?
N/A
Yes
31. What is the main occupation of the
No breadwinner?
If yes, which one? ........................... Informal employment
23. (observe) is there kitchen garden with Business
vegetable? Farming
Yes Formal employment
No Artisan
24. What did you eat for supper last night? 32. Indicate the types of assets that you
........................................... own;(car, motorbike, cow, goat, sheep,
25. What did/will you eat for lunch today? hen, television, radio)
........................................ ………………………………..
26. What will you ate for supper today? …………………………………..
………………………………….
...........................................
……………………………………
27. Based on the above responses, is that a
…………………………………..
balanced diet?
……………………………………..
Yes
…………………………………..
No
28. Are there cultures that hinder
SECTION F: MORBIDITY AND
nutrition?
Yes MORTALITY
No 33. Has any member of this home been sick
29. If Yes, which cultures are these? in the last one month?
…………………………………………………………… Yes
No
……………………………………………………………
If Yes, how many members? ………………
……………………………………………………………
34. How old is the family member who got
……………………………………………………
sick lastly? ....................................
What were the major complain?
Stomachache
Accident
 Headache
Joint pain
Fever
N/A
Where did the patient get treated?
Traditional healer
Local chemist
Family friend
Hospital
No treatment
N/A
35. Has any of the family members dead in
the past 6months?
Yes
No
If Yes, what was the age of the
deceased? [ ]

SECTION G: PHYSICAL
ENVIRONMENT
36. What is the condition of the house?
Leaky roof
Cracked walls
Dusty
Congested
Poorly ventilated
37. How many rooms does the house have?
1
2
3
More than 3
38. Is there presence of bushy surrounding?
Yes
No