Universidad De Dagupan (formerly Computronix College)

Arellano St., Dagupan City

School of Health Sciences-College of Nursing
B. FAMILY STRUCTURE

1. Type of Family Structure

______ Extended

______Single parent

______Blended

______Nuclear

______Foster parent

2. Family Decision-maker

______Father

______Mother

______Both

______Others; Please specify __________________________

C. SOCIO-ECONOMIC PROFILE

1. Religion

______Catholic

______Protestant/ Independiente

______Jehovah’s Witness

______Mormons

______Iglesia ni Cristo

______Born Again Christian

______7th day Adventist

______Others; Please specify __________________________

2. Ownership status of your house

______Caretaker/ free

______Rented

______Owned

3. Ownership status of the lot in which your house is built

______Squatter
______Caretaker

______Rented/ Leased

______Common property with other family members

______Owned

4. Type of Dwelling Unit/Structure

______Permanent (concrete)

______Semi-permanent (wood)

______Temporary (nipa hut)

______Makeshift

5. Number of Bedrooms

______ 5-6

______ 3-4

______1-2

______ Others; Please specify

6. Availability of Private Vehicle at home

______Yes

______No

D. ENVIRONMENTAL HEALTH

1. Availability of common garbage bin inside the house

______Yes ________close ________open

______No

2. Source of drinking water

______Dug well

______Commercial water

______ Shared tube/pipe

______Own use tube/ pipe

______ Shared faucet, community water system

______Owned use faucet, community water system

______Others; Please specify

__________________________

3. Drinking Water Storage

______1. Tank

______2. Drum/ can

______3. Earthen jars/pots

______4. Plastic containers

______5. Electric powered dispenser

______6. Others: ________________

4. Food Storage

______1. Cabinet

______2. Open shelves

______3. Refrigerator

______4. Others: ________________

5. Drainage System

______1. Not available

______2. Open

______3. Blind

6. Toilet Facilities

______1. Not available

______2. Open pit

______3. Closed pit

______4. Water-sealed, shared with other households

______5. Water-sealed, used exclusively by the household

______6. Flush toilet

7. Garbage Disposal

______1. Municipal garbage collection

______2. Communal pit

______3. Open dumping

______4. Burning

______5. Composting

______6. Others: ___________

8.Observance of Garbage Segregation

______1. Yes

______2. No

E. FAMILY HEALTH ORGANIZATION

1. Number of Alive Children

________ 1

________ 2

________ 3

________ 4. Others:

2. Number of Deceased Children 18 years old and below

________ 1

________ 2

________ 3

________ 4. Others:

Causes of Death:

______________________

3. Common illnesses of Children in the family (within the last 2 years)

__________________________________________

4. Common illnesses of the elderly in the family (within the last 2 years), write NA, if not applicable

__________________________________________

5. Children Immunizations (for children 0-18 months only)

Type of Immunizations

NAME AGE BCG POLIO DPT HEPA B MMR

(OPV)
6.Family Planning Acceptor

________1. If Yes, Indicate age

________2. No

A. Natural Methods

________1. Withdrawal

________2. Abstinence

________3. Calendar method

B. Artificial methods:

________4. Condom

________5. Intra-Uterine Device (IUD)

________6. Pills

________7. Injectables (DEPO)

C. Surgical methods

________8. Ligations (BTL)

________9. Vasectomy

Others: __________________

7. Health Resources Availed from for the last 2 years

________1. Government Hospital

________2. Private Hospital/ Clinic

________3. Main Health Center

________4. Barangay Health Station

________5. Private Medical Practitioner

________6. Barangay Health Workers

________7. Hilot

________8. Herbolario

________9. Others: ________________

8. Covid 19 Pandemic Status

A. How does your family prevent from being infected with Covid 19? You

may check as more than 1 answer.

________1. Wear mask when they go outside the house

________2. Wear facemask and face shield when they go outside the house

________3. Take vitamins everyday

________4. Stay at home

________5. Perform hand hygiene often

________6. Sanitize the house

________7. Physical exercises ex. Zumba

________8. Eat healthy foods ex. Low fat, low salt, low sugar

B. Where do you get information to prevent Covid 19?

________1. Television

________ 2. Radio

________ 3. Newspapers

________ 4. Internet

C. How do you rate your family coping with the Covid 19 pandemic in a

scale of 1-10, where 10 is highest?

_____________

D. What aspect of your current family status in the Covid 19 pandemic is affecting most?

________1. Financial

________2. Socio-emotional

________3. Spiritual

________4. Physical

E. How do you deal with this aspect that is affecting your family most?

________1. Ask for help from the government/government agencies

________2. Ask for help from the relatives

________3. Ask for help from employer

________4. Ask for help from friends

________5. Others; _____________________________

F. How long do you think the pandemic will lasts?

________1. One year

________2. Two years

________3. Three years

________4. Others: _____________________________