ARELLANO UNIVERSITY

SCHOOL OF MIDWIFERY
2600 Legarda St. Sampaloc, Metro Manila
Telephone No. 87347371
www.arellano.edu.ph

INTERVIEW QUESTIONNAIRE
INITIAL DATA FOR FAMILY ASSESSMENT
PART I. Identification Information
Date:______________
Name of Head of the Family:______________________________________________________
Address: House No.:___________, Street:___________________________________________
Municipal/City:_____________________________________________________________________
Religion:_____________

No. Name Relation Gender Birth Age Civil Highest Occupation Employment
to head date Statu Education Status
s Completed
1.(Head
of the
Family
2.
Spouse
3.
Eldest
child
4.
5.
6.
7.
8.
9.
10.

Total Monthly Income of Household:

[ ] below 5,000/month [ ] Php 10,000-15,000/month
[ ] Php 5,000-10,000/month [ ] Php 15,000-20,000/month [ ] above 20,000/month

How much of your income are you spending: (Please use percentage, for each item, a total of 100%)
 Food __________%
 Clothing________%
 Education_______%
 Health__________%
 Transportation____%
 Medication_______%
 Leisure_________%
 Others__________%
________________
Total___________%

PART II. Environmental Factors

Home Ownership:
[ ] owned [ ] shared [ ]rental

Housing:

Adequacy of living space:

Number of rooms: [ ] 1 room [ ] 2 rooms [ ] 3 rooms
Number of person/s per room: ____________(specify)

Housing Structure:
[ ] concrete (strong material) [ ] mixed (combination of wood and concrete)
[ ] light (wood, lumber)

Ventilation:
[ ] well ventilated [ ] poorly ventilated

Number of windows per household:

[]1 []2 []3 []4

Lighting Facilities:
[ ] electric bulb [ ] used of kerosene lamp [ ] others________

Condition of Lightning Facilities:

[ ] well lighted [ ] poorly lighted

Sources of Electricity:
[ ] owned [ ] shared
 ARELLANO UNIVERSITY
SCHOOL OF MIDWIFERY
2600 Legarda St. Sampaloc, Metro Manila
Telephone No. 87347371
www.arellano.edu.ph

General Sanitary Condition of the house:

[ ] clean [ ] dirty [ ] disorderly

Environment proximal to the house:

[ ] near factories [ ] near dumpsite [ ] near main road
[ ] near creek/river [ ] near the fields

Toilet Facility:
Type of Latrine:
[ ] water-sealed [ ] flush-type [ ] open pit-hole privy
[ ] over-hung lantrine [ ] antipolo-type [ ] closed pit-hole privy

Location of Toilet:
[ ] inside the house [ ] outside the house

Ownership of Toilet:
[ ] owned [ ] shared [ ] public toilet

Sanitary Condition of Toilet:

[ ] clean [ ] very dirty [ ] dirty
[ ] with flies over [ ] stinks

Frequency of Cleaning the toilet:

[ ] cleaned everyday [ ] cleaned once a week [ ] not cleaned at all

Status of Electricity:
[ ] owned [ ] shared

Garbage Disposal:
[ ] thrown/open dumping [ ] collected (frequency)_________ X a week
[ ] open burning [ ] composting
[ ] burial pit

Presence of Pollution:
[ ] air [ ] water [ ] land [ ] noise

Kind of neighborhood:
[ ] slum [ ] congested [ ] subdivision

Drainage:
[ ] close drainage [ ] open drainage [ ] none

Infestation of Insect and Rodents:

Are insect and rodents present:
[ ] yes [ ] no

What type of rodent and insects are present:

[ ] mouse/rat [ ] flies [ ] cockroach [ ] mosquito

How does it affect your living?

[ ] 100% affects the way of living
[ ] 50% affects the way of living
[ ] does not affect at all

Presence of Domestic animals:

Kind of Animal Number Where kept:
[ ] dogs ______ [ ] loose [ ] tied/kept in backyard
[ ] cats ______ [ ] loose [ ] tied/kept in backyard
[ ] ducks ______ [ ] loose [ ] tied/kept in backyard
[ ] chicken ______ [ ] loose [ ] tied/kept in backyard
[ ] pigs ______ [ ] loose [ ] tied/kept in backyard
[ ] others ______ [ ] loose [ ] tied/kept in backyard

If with dogs, are they vaccinated or not?

[ ] vaccinated [ ] unvaccinated

Where does domestic manure (pigs, ducks, chicken) are being dispose:
[ ] open dumping [ ] recycled [ ] thrown [ ] others

Food storage and cooking facilities

Where do you cook you food?

[ ] gas range [ ] firewood [ ]charcoal [ ] pugon
[ ] electric stove [ ] others

How do you store your food?

[ ] stored in the refrigerator [ ] sealed or covered [ ] no seal or cover at all

Water Supply:
Source of Drinking Water:
[ ] Maynilad [ ] deep well [ ] artesian well [ ] Water station (refilling)

Ways of acquiring water:

 ARELLANO UNIVERSITY
SCHOOL OF MIDWIFERY
2600 Legarda St. Sampaloc, Metro Manila
Telephone No. 87347371
www.arellano.edu.ph

[ ] through owned line [ ] shared [ ] bought per container

Ways of water storage

[ ] covered container [ ] uncovered container [ ] others

Perception of Respondents to the Community in General:

General Sanitary Condition:
[ ] clean [ ] dirty [ ] street cluttered with litter

Housing Congestion:
[ ] good/adequate [ ] poor/congested [ ] disorderly

Presence of Breeding Sites of Vectors of Diseases:

[ ] slow flowing mountain stream [ ] rivers
[ ] garbage dump/pile [ ] drainage

Recreational Facilities:
[ ] Parks [ ] playground
[ ] Amusement Center [ ] Sports Facilities

Availability of Health Care Facilities within the community:

[ ] government health center [ ] private clinics
[ ] government health hospital [ ] private hospital
[ ] private dental clinics [ ] rehabilitation centers

PART III. Health Assessment of Each Member

Medical History

Family History of Disease

[ ] Diabetes [ ] Tuberculosis [ ] Heart Disease
[ ] Hypertension [ ] Hepatitis B/C [ ] Mental Illness
[ ] Asthma [ ] Food Allergy [ ] Hemophilia
[ ] Cancer [ ] Skin Allergy/Skin Disease [ ] Abnormalities

Present Illness (starting June 2022)

[ ] Diabetes [ ] Tuberculosis [ ] Heart Disease
[ ] Hypertension [ ] Hepatitis A [ ] Fracture
[ ] Asthma [ ] Food Allergy [ ] Diarrhea (more than 3 days)
[ ] Cancer [ ] Skin Allergy [ ] Respiratory Illness (cough more than 1 week)
[ ] Typhoid Fever [ ] Bleeding [ ] Dengue Fever
[ ] Anemia [ ] Malnutrition [ ] others:________________

Chronic Illness
[ ] Diabetes [ ] Tuberculosis [ ] Heart Disease
[ ] Hypertension [ ] Hepatitis B/C [ ] Cancer

Sources of Health Care of Family: (frequently used service)

[ ] Health Center [ ] Private Clinics [ ] Traditional Doctor
[ ] Private Hospital [ ] Government Hospital [ ] Others_________(specify)

Source of Health Insurance:

[ ] SSS [ ] Philhealth [ ] Private Health Card [ ] Others_________(specify)

Immunization against:
[ ] Influenza [ ] Covid 19
[ ] Cervical cancer/HPV
[ ] H1N1

Vices
[ ] smoking ___________(note number of sticks per day)
[ ] alcoholism _________(note number of bottles per day)
[ ] prohibited drugs_______(specify)

Beliefs and Practices in case of emergency medical problem:

[ ] consult medical practitioner
[ ] use herbal medicine
[ ] consult hilot, albularyo and ispiritista
[ ] self medication/self-treatment
[ ] traditional therapy such as reflexology, acupressure, acupuncture
[ ] others

For Females:
Do you conduct or submit yourself for the following procedure:
[ ] Monthly self breast examination
[ ] yearly Pap Smear
[ ] annual physical examination
[ ] others

For Males:
Do you conduct or submit yourself for the following procedure:
[ ] Testicular Examination
[ ] annual physical examination
 ARELLANO UNIVERSITY
SCHOOL OF MIDWIFERY
2600 Legarda St. Sampaloc, Metro Manila
Telephone No. 87347371
www.arellano.edu.ph

[ ] others

Nutritional Assessment

Typical Diet per day:

[ ] vegetarian [ ] carnivorous [ ]mixed

Food Preference when cooked:

[ ]inihaw/grilled [ ]nilaga/boiled or blanch [ ]ginisa/sautéed

Sources of food:
[ ] self-produced [ ] from the market

Budget for food from monthly income:

[ ] 100% [ ] 75% [ ]50% [ ] 25%

Quantity of meal per day:

[ ]6 x a day [ ] 5x a day [ ]4x a day [ ]3 x a day [ ]2 x a day [ ] 1 x a day

For Pregnant Women only:

Reproductive System Assessment (For mother and pregnant mothers)
[ ] age of menarche______________
[ ] Obstetrics History G__ T__ P__ A__ L__

Name of Child Delivered by: Place of Delivery Type of Delivery AOG/Term

Pre-Natal Check-Up:
[ ] LMP_____ [ ] EDC______ [ ] AOG_____

[ ] First Trimester [ ] Second Trimester [ ] Third Trimester

Consultation:
[ ] every month [ ] twice a month [ ] weekly [ ] none at all

Place of Consultation
[ ] Health Center [ ] Government Hospital
[ ] Lying In Clinic [ ] Private Hospital

Preferred place of Delivery:

[ ] Health Center [ ] Government Hospital [ ] Home
[ ] Lying In Clinic [ ] Private Hospital

Preferred Birth Attendant:

[ ] Doctor [ ] Midwife [ ] Hilot

Illness/ Complication Encountered during Pregnancy:

[ ] Bleeding [ ] Convulsion [ ] Edema [ ] Elevation of Blood Pressure
[ ] Placenta Previa [ ] Abruptio Placenta [ ] Pre-Eclampsia [ ] Preterm Abdominal pain
[ ] Malnutrition [ ] Infection [ ] Anemia
[ ] Blurred vision [ ] Dizziness

Complication Encountered during Labor and Delivery:

[ ] Elevation of Blood Pressure [ ] Fetal Distress/Arrest in Descent
[ ] Eclampsia [ ] Bleeding

Medication during Pregnancy:

[ ] Multi-Vitamins [ ] Calcium [ ] others___________(specify)
[ ] Folic Acid [ ] Ferrous Sulfate

Immunization of Tetanus Toxoid

TT1 As early as possible during pregnancy Done (Completed) (Write Check)
TT2 At least 4 weeks after TT1
TT3 At the 5th-6th month of succeeding pregnancy
regardless of interval from previous
pregnancy
TT4 At least one year later
TT5 At least one year later

How many children you would want to have?_____________ (specify)

Choice of Family Planning:

Artificial Method
[ ] Condom [ ] IUD [ ] Pills [ ] Injectables (Depovera)

Natural Method
[ ] Withdrawal [ ] Abstinence [ ] Lactated Amenorrhea Method
[ ] Calendar Method [ ] Billing Method
 ARELLANO UNIVERSITY
SCHOOL OF MIDWIFERY
2600 Legarda St. Sampaloc, Metro Manila
Telephone No. 87347371
www.arellano.edu.ph

Caring for Infant 0-12 months old:

Type of infant feeding :
[ ] Breastfeeding [ ] Bottle feeding [ ] Mixed

Reason for not breastfeeding, indicate reason/s_________________________________

If bottlefed, what type of substitute milk is used?

[ ] powdered milk [ ] condensed milk
[ ] Am [ ] water with sugar/glucose solution

Immunization:
Immunization with Children 0-12 months
Name of Child Age Immunization Received (Please Remarks/Evaluation
Check) Complete/Incomplete
[ ] BCG [ ]DPT (3)
[ ] OPV (3) [ ] Measles
[ ] Hepatitis B (3)
[ ] BCG [ ]DPT (3)
[ ] OPV (3) [ ] Measles
[ ] Hepatitis B (3)
[ ] BCG [ ]DPT (3)
[ ] OPV (3) [ ] Measles
[ ] Hepatitis B (3)
[ ] BCG [ ]DPT (3)
[ ] OPV (3) [ ] Measles
[ ] Hepatitis B (3)
[ ] BCG [ ]DPT (3)
[ ] OPV (3) [ ] Measles
[ ] Hepatitis B (3)

Status of Child Immunization

[ ] Complete Immunization
[ ] Incomplete Immunization (please indicate reason/s: Specify______________

Hospitalized member of the family (since June 2022 up to the present):

Name Age Gender Date Admitted in Diagnosis Medical /Surgical
Hospital Management

Deaths from June 2022 up to the present

Name Age Gender Date Died Cause of Death Relationship

JPReyes 2023