APPENDICES
SAINT MARY’S UNIVERSITY
Bayombong, Nueva Vizcaya
SCHOOL OF HEALTH SCIENCES
COMMUNITY SURVEY FORM
MUNICIPALITY : _________________________ DATE: ______________ BARANGAY NAME : _________________________
PUROK : _________________________
HOUSE NUMBER : _________________________
I. Family Data/ Profile
Father Mother
Name:
Addresses:
Length of residency:
Birthdate & age:
Place of birth:
Ethnicity: Ilocano ( ) Gaddang ( ) Ifugao ( ) Ilocano ( ) Gaddang ( ) Ifugao ( ) Igorot ( )
Igorot ( ) Others:_______________________ Others:______________________
Educational attainment: Elem grad ( ) Elem undergrad ( ) High school grad Elem grad ( ) Elem undergrad ( ) High school grad
( ) High school undergrad ( ) College grad ( ) ( ) High school undergrad ( ) College grad ( )
College undergrad ( ) College undergrad ( )
Religion: Roman Catholic ( ) Methodist ( ) INC ( ) Roman Catholic ( ) Methodist ( ) INC ( )
Methodist ( ) Espiritista ( ) Methodist ( ) Espiritista ( )
Born Again ( ) Others:________________ Born Again ( ) Others:________________
Occupation: Farming ( ) Businessman ( ) OFW ( ) Laborer ( ) Farmer ( ) Businessman ( ) OFW ( ) Laborer ( )
None . None .
Gardening ( ) Piggery ( ) Poultry ( ) Gardening ( ) Piggery ( ) Poultry ( )
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Vendor ( ) Others: ________________ Vendor ( ) Others: ________________
Occupational status: Permanent ( ) Self-employed ( ) Contractual ( ) Permanent ( ) Self-employed ( ) Contractual ( )
Probationary ( ) Temporary ( ) Probationary ( ) Temporary ( )
Type of family: Nuclear ( ) Extended ( ) Single parent ( ) Couple w/out children ( ) Others:______________
Marital status: Married ( ) Live in ( ) Widow ( ) Widower ( ) Separated ( )
II. Members of the Household (Family members first before significant others and this includes members currently living with the family)
Name Relati Birthdate Age Sex Civil Education Religion Occupation Ethnicity
on to Status al
head attainmen
t
III. Socio-economic Data
Husband Wife
A. Family Weekly: Weekly
weekly/monthly
income Monthly: Monthly:
Other Members : Other members
B. Allocation of 1. Food
family income
(monthly basis) 2. Clothing:
3. Housing:
4. Schooling:
5. Others: Ex. (Medicine)
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Income vs expenses Adequate ( ) ( ) Inadequate
Explain why?
C. Nutrition A. Food preferences ( every family members)
Fish ( ) Meat ( ) Fruits & Vegetable ( ) Mixed ( )
B. Common Food every meal for the family
Breakfast :
Lunch :
Dinner:
Please describe the quantity and quality of food. ( 24 hour recall method)
IV. Housing and Environmental Condition
A. Housing condition Concrete ( ) Semi-concrete ( ) Wooden ( ) Bamboo ( ) Mixed ( ) Others:
1.Type of housing ________________________
2. Ownership Owned ( ) Rented ( ) Rent-free ( ) Others: ______________________
3. Number of room None ( ) One ( ) Two ( ) Three ( ) Others: ____________________ Size of
for Sleeping the room :
4. Ventilation Adequate ( ) Inadequate ( ) Why ? describe further ( size windows, doors)
5. Lighting facility Electricity ( ) Kerosene lamp ( ) Others: __________________________ Adequate ( )
Inadequate ( ) describe further during day and night ( size windows, doors)
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6. General surroundings (Identify health threats / presence of breeding site of vector ,describe the general
of the house: (inside and sanitation ) Inside :
outside)
Outside:
Drainage system Open ( ) Closed ( ) Describe the drainage and also the sanitary condition:
B. Food storage Appropriately kept ( ) Inappropriately kept ( ) Others: ________________________
Why? Describe and discuss further :
D. Source of water Artesian well ( ) Deep well ( ) Spring ( ) others:
supply for daily May describe the source :
consumption
E. Source of drinking Artesian well ( ) Deep well ( ) Spring ( ) others:
Water May describe the source and potability of water for drinking:
F. Storage of drinking Covered ( ) Uncovered ( ) Refrigerated ( ) Others: __________
Water
G. Water treatment Boiling ( ) Chlorination ( ) Sun exposure ( ) Water purifier ( )
H. Containers Used Plastic w/ cover ( ) Plastic w/out cover ( ) Jar w/ cover ( ) Jar w/out cover ( ) Bottles
for drinking water w/ cover ( ) Bottles w/out cover ( ) Others: _________________
I. Distance of source 5 meters ( ) 10 meters ( ) 20 meters ( ) Others: __________
of water to the
toilet
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J. Toilet Facilities Owned ( ) Shared ( ) Communal ( ) Public ( )
Flush ( ) Water sealed ( ) Closed pit privy ( ) Open pit privy ( )
Others: _____________________
K. Sanitary condition (Describe)
of the toilet
L. Presence of bin for Biodegradable ( ) Non-biodegradable --- Residual waste / Non-recyclable ( )
waste Segregation Recyclable ( ) Reusable ( )
Discuss what composes the garbages :
M. Methods garbage Collection ( ) Burning ( ) Burying ( ) Open dumping ( )
Disposal Others: _____________________
N. Presence of astray Dogs ( ) Cats ( ) Pigs ( ) Goats ( ) Chickens ( ) Ducks ( ) Others:
Animals ____________________
O. Backyard Gardening Vegetables ( ) Herbal ( ) Fruit-bearing ( )
Others:
________________
V. Community Observation and Resources (Write your own observation) The output per group will be collated as one.
a. Sanitary condition
(Describe the area of assignment)
b. Houses—overcrowded /congested Yes ( ) No ( )
Why? describe further :
c. Presence of breeding sites of vector Yes ( ) No ( ) If yes ,specify: _______________________________________
d. Presence of health and Health center ( ) Barangay hall ( ) School ( ) Church ( ) Park ( ) Market ( )
other facilities Others: __________________
e. Presence of recreational facilities Yes ( ) No ( ) If yes, specify: _______________________________________
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f. Presence of indigenous Trained hilot ( ) Herbolaryo ( ) Spiritual healer ( )
health worker Others: _____________________
g. Distance of family house to Barangay health center __________________ RHU _____________________
health care facility (meters /km)
VI. Knowledge, Attitude, and Practices
A. Do the family utilize If No, Why? ______________________________________
the barangay If Yes
health center? How often : ________ No. of times : ______
Reason for utilizing the BHS:
Illness ( ) please specify :_________________________
Family planning ( ) Prenatal Post natal ( ) Immunization ( )
Others: ________________________
C. Do the family utilize If No, Why? ______________________________________
the RHU? If Yes
How often : ________ No. of times : ______
Reason for utilizing the BHS:
Illness ( ) please specify :___________________________
Family planning ( ) Prenatal Post natal ( ) Immunization ( ) Laboratory ( )
Delivery ( ) Dental ( ) Medicine ( )
Others: ________________________
OTHER SOURCE FOR If No, Why? ______________________________________
HEALTHCARE ( Hospital If Yes
or private clinics) How often : ________ No. of times : ______
Reason for utilizing the BHS:
Illness ( ) please specify :___________________________
Family planning ( ) Prenatal Post natal ( ) Immunization ( ) Laboratory ( )
Delivery ( ) Dental ( ) Medicine ( )
Others: ________________________
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D. Initial management Self-medication ( ) Consult a doctor ( ) Nurse ( ) Midwife ( ) Herbularyo ( ) Others:
when illness arise: ________________________________
VII. Health Assessment of each family member
A. Older Members ( for pregnant or postpartum please use the part VIII
Name Weight Height Current Health Past Health Problem Common Illness
Problem
B. Under Five Members ( Breastfeeding)
Name Weight Height Current Past Health Comm Immunizati Deworming
Health Problem on on ( Pls. Date Given
Problem Illness Specify)
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Nutritional Assessment for vulnerable or at risk members (Compute first the BMI)
Name of member: ______________________________________________________
Discuss the dietary history in details ( Quantity and Quality of food intake per
day :_____________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
____________________________________________
Eating and Feeding Habits/Practices
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
__________________________________________________________________
VIII. Data for Antepartum or Postpartum Clients if any
NAME:
LMP
AOG
GPTPALM
EDC
Weight Pre-pregnancy : ( Kg) Current Pregnancy : (Kg)
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Height
Vital Signs T-__________ P-___________ R-__________ BP-__________
Pre-natal check up Barangay health center ( ) RHU ( ) Hospital ( ) Private clinic ( )
Chief
complaints/Discomforts (at
present)
Current Health Condition
Complications during
pregnancy
Past Health Condition
( not related to
pregnancy)
History of Previous Pregnancy (for members who are within the reproductive age )
Pregnancy Mode of Delivery Place of Delivery Attended by Complications
NSD/CS
G1
G2
G3
G4
G5
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OTHER MEMBER
History of Previous Pregnancy (for members who are within the reproductive age )
Pregnancy Mode of Delivery Place of Delivery Attended by Complications
NSD/CS
G1
G2
G3
G4
G5
________________________________________________
NAME AND SIGNATURE OF STUDENT
____________________________________________
CHECKED BY ( NAME AND SIGNITURE OF INSTRUCTOR)
Prepared By:
JULITA J. RODRIGUEZ, RN MSN
MARYJEAN CALLEJO RN, MSN
MARISSA LYN LABANGCOC, RN MSN
THELMA DELOS REYES, RN MSN
PETER- TOM CALLANG, RN MSN
JOAN TAROMA, RN MSN
JANICE ASUIT,RN,MSN
CHN RLE INSTRUCTORS
REVISED 2016
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