Benguet State University

COLLEGE OF NURSING
La Trinidad, Benguet
Tel.No (074) 422-2127 loc 36
HOUSEHOLD SURVEY TOOL
Barangay: _________________________________ Sitio: __________________________________
Name of Household Head: ____________________ Length of Residency: _____________________
Name of Informant: _________________________
I. SOCIO-ECONOMIC PROFILE
1. Household Composition (Include Informant and HH Head)
Name of Household Date of Age Sex Civil Status Religion Relationship to Educational Occupation Monthly Income
Members: Birth HH Head Attaintment and Place of
(m/d/y) Occupation

Family No:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Family No:
1.
2.
3.
4.
5
Family No:
1.
2.
3.
4.
Type of Family According to Organization/Members Type of Family According to Authority
o Nuclear o Extended o Blended o Patriarchal o Matriarchal o Egalitarian o Matricentric
 2. Dwelling Unit

1. Type of Housing 2. Status of Occupancy 3. Sleeping Area 4. Appliances in the 5. Source of lighting 6.Materials for cooking 7. Lot ownership
Unit (housing unit) house
o Concrete o Owned  Number of  ___________ o Electricity o Electricity o Owned
o Concrete o Rented rooms used in  ___________ o Kerosene o Kerosene o Rented
and wood o Others,please sleeping  ___________ o LPG o LPG o Others,please
o Wood and specify: ______  ___________ o Others,please o Wood specify:
G.I. _____________  How many  ___________ specify: o Others,please _____________
o Makeshift person/room  ___________ _____________ specify:
___________ _____________

II. HEALTH STATUS OF CHILDREN 0-6 YEARS

Name of Child Ht Wt Child’s Birth Place of Breastfeed for 6 months or more Immunization
Attendant Delivery (please check/write the date given if possible
Yes No Why? BCG DPT OPV Measles Hep-B
Doses 1 2 3 1 2 3 1 2 3 1 2 3
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
III. MATERNAL HEALTH

Name of HH Member How many Tetanus Toxoid Place where she had Prenatal Care How often? Attending Personnel
Currently Pregnant months Yes No Why? injection Yes No Why
1.
2.
3.
4.
5.
Past pregnancies: Did the mothers who were pregnant sought prenatal care?
o Yes, who was the health personnel approached?
 o No, Why?

IV. FAMILY PLANNING

1. Are you/ or your spouse currently using or 2. Have you/ or your spouse used or practiced 3. If yes to either 1 or 2, who taught you how to
practicing any Family Planning method? any Family Planning method? use this method?
o Yes, what method? _______________ o Yes, what method? _______________ ____________________________________________
o No, why? _______________________ o No, why? _______________________ ____________________________________________
V. GENERAL HEALTH PRACTICES
1. Where do you usually/commonly seek assistance/ consultation for your 2. Reasons for choosing the place of consultation?
illness?
Others (enumerate) ___________________________________________________ Others (enumerate) ___________________________________________________
_________________________________________________________ _________________________________________________________

VI. ENVIRONMENTAL HEALTH

1. Main source of water 2. What do you use 3. What toilet facilities 4. Garbage disposal 5. Drainage System 6. Domestic
for storing water? do you have? facility Animals
Kind No. Where
Kept?

o Tap/faucet o Tanks o Water Sealed o Common pit o Open

o Rain-water o Plastic container o Closed Pit o Open dumping o Blind
o Spring o Drums o None o Individual pit o None
o Well o Bottles o Open pit o Burning o Others, please
o Others, please specify o Others, please specify o Flush type o Others, please specify
___________________ ________________ o Others, please specify specify _____________
__________________ ________________
Are there breeding sites of insects/ rodents, etc present? ______________ _______ Are there accident hazard present? ________________________
VII. MORBIDITY RECORD
Name of household member Type of Illness Date of Illness Who treated the sick member Where was he/she Was the
brought for treatment treatment
effective?
Yes No

1.
2.
3.
4.
5.
6.
7.
 8.

VIII. MORTALITY CASES (for the past 6 months)

Name of Household Age of Death Cause of death Given medical treatment prior to death?
member If YES, WHERE and WHO provided the treatment? If no, why not?
WHERE PROVIDER
1.
2.
3.
4.
5.
6.
7.
8.
IX. PERCEIVED COMMUNITY HEALTH PROBLEMS
1. What is/ are the common health problems in the community? 2. What do you think is/ are the solutions to the most serious problem?
List them from the perceived most serious to the least.
a. a)
b. b)
c. c)
d. d)
e. e)
f. f)
g. g)
h. h)
i. i)
j. j)
X. THE COMMUNITY IN GENERAL
General sanitary condition Housing Recreational facilities Availability of health care facilities Distance of the house from
congestion the nearest health care
Yes No facility

Name of Student (Name and Signature)

Area
Date area was assessed
Clinical Instructor (Name and Signature)