COMMUNITY SURVEY
Respondent:_______Allysa Mendoza____________________ Barangay No.____none_____
Interviewer:________________________________________ Household No. _____none__
Date of Survey: _____nov 5 ,2020________________________________
I. FAMILY DATA
a) Name of Husband _______Alberto G. Mendoza_______________________ Age : ___60___
b) Name of Wife ___________Teodocia E. Mendoza______________________ Age : ___60__
c) Address __sitio ibabao ambulong batangas city______________________________
d) Educational Attainment (highest)
Husband_______highschoo___________ Wife ___________3 rd college_____________
e) Length of Residency (on above address)_______________________________________
f) Family Size ____________5_____________ g) Religion ________catholic ____
h) Place of Origin _____________________________ i) No. of Children_____5 ___
Highest Educational
Name Age Sex Status Occupation
Attainment
Alberto G. Mendoza 60 M Marrie Highschool ofw
d
Teodocia E. Mendoza 60 F Marrie 3rd yr college ofw
d
Albert heissen E. Mendoza 29 M Marrie 2nd yr college ofw
d
Albert Angelo E. Mendoza 21 M single 3rd yr college and none
going
Allysa Mae E. Mendoza 20 F F 2nd yr college and none
single going
II. SOCIO-ECONOMIC DATA:
A) Source of Income: 15k-20k
Occupation: Father:____________ofw__________________ Mother:__________ofw______________
Other Source of Income:__________15k-25k________________
B) Monthly Family Income: ________20k-50k__________________
C) Is your lot owned? ( / ) Yes ( ) No Why _________________________
III. HOUSING AND ENVIRONMENTAL CONDITION:
a) Type of Housing:
( / ) concrete ( ) mixed ( ) wood ( ) makeshift Others/specify:_______________
b) Source of water supply:
( ) protected well ( / ) water work system ( ) open dug well ( ) rain water
( ) communal faucet (stand post) ( ) deep well ( ) spring ( ) river lake
Others/Specify:__________________________________
c) How is drinking water stored?
( / ) refrigerated ( ) covered ( ) uncovered
d) Toilet facilities:
( / ) owned ( ) shared ( ) public
Type: ( ) pit latrine ( ) bored hole latrine ( ) aqua privies ( ) flush system
Garbage disposal:
( / ) burning ( ) flying saucer( ) MMA Collection
( / ) open dumping ( ) garbage collector Others/specify _____________________
e) Food preferences:
( / ) fish ( ) vegetable ( ) combination
( / ) pork ( ) beef ( ) others: specify______________________
How is food stored?
( ) covered ( ) uncovered ( / ) refrigerated
Are you using iodized salt? ( ) Yes ( ) No
For how long? ( / ) Weeks ( ) Months ( ) Years
f) Gardening:
( ) fruitbearing ( / ) herbal ( ) ornamental plants
g) Animal or pet:
( / ) dog ( / ) cat ( ) chicken ( ) fish ( ) bird ( ) others:
specify:__________________
h) Common household pests/insects:
( / ) mosquitoes ( ) flies ( / ) cockroaches ( ) rats ( ) others: specify:_____________
IV. GENETIC/HEREDITARY ILLNESS/ILLNESSES IN THE FAMILY
( ) Hypertension ( ) Cancer ( / ) Diabetes Mellitus ( ) Asthma
( ) Cardiovascular Disease ( ) Leprosy Others/specify ______________________
V. KNOWLEDGE, ATTITUDES AND PRACTICES:
a) What are the usual illness/illnesses encountered in the family ?
______diabetes________________________
____________________________________________________________________________
b) At present, any family member with health problem/illness? ( / )Yes ( ) No
Please specify: ___________________________ For how long? ________a month__________
VI. HEALTH RELATED RESOURCES
a) Do you utilize the health center: ( / ) Yes ( ) No
b) For what reason?
( ) morbidity ( / ) family planning ( ) immunization
( ) dental ( ) laboratory ( ) pre-natal ( ) post natal
c) First person consulted in time of illness:
( ) private doctor ( ) RHU doctor ( / ) nurse ( ) midwife
( ) herbolario ( ) spiritists ( ) health volunteers ( ) others: specify: ________
d) What health agencies are you familiar with and those services you have used:
____________________________________________________________________________
VII. PREGNANCY-RELATED INFORMATION
a) OB History ( ) gravida (No. of pregnancy) ________ Living Children ________
b) Manner of Delivery ( / ) caesarian ( ) normal
c) Immunization ( ) Tetanus Toxoid
d) Type of Family Planning Method
( ) pills ( ) IUD ( / ) condoms Others/specify ____________
( ) injection ( ) ligation ( ) vasectomy
VIII. POST-NATAL CARE
Immunization
Fully immunized child ( / ) yes ( ) no
Children below 8 years of age
( ) BCG ( ) DPT ( ) OPV ( ) Hepa ( ) Measles Others/specify ___________
VIII. COMMUNITY RESOURCES:
( / ) Health Center ( ) market ( ) school ( ) cemetery
( ) park ( ) community hall Others/specify:
