COMMUNITY DIAGNOSIS QUESTIONNAIRE

Control No.___028___
1. City/ Municipality: ___________Binmaley___________ 4. Household Identification number: __________028_________
2. Barangay: __________Pallas______ 5. Initials of the Respondent: R.F.S, R.G.S, R.G.S, R.G.S, R.G.S
3. Address (no. and street name): ____________028_________

A. HOUSEHOLD MEMBERS
NAME Relation To Household AGE SEX CIVIL HIGHEST LEVEL CURRENT EMPLOYMENT
(Initials only) Head 1-male STATUS( 18 1. Elementary level C.1 -Healthcare (Government)
Start With The 1-head of the 2female y/o AND 2. Elementary C.2 -Healthcare (Private)
Head Of The household ABOVE) Graduate C.3 –NonHealthcare (Government)
family 2-spouse 1. single 3. High School level C.4 –NonHealthcare (Private)
3-son/daughter 2. married 4. High School C.5 –NonHealthcare (Private)
4- father/mother 3. widow/ Graduate C.6 –Not Applicable
5-grandchildren widower 5. College Level
6-grandparents 6. College Graduate
7-other relatives 7. Master’s /Doctoral
8-non-relatives Degree Level
8. Masters/Doctoral
Graduate
1. R.F.S 1 48 1 2 4 4

2. R.G.S 2 47 2 2 4 6

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3. R.G.S 7 25 2 2 6 3

4. R.G.S 7 24 2 1 6 3

5. R.G.S 7 21 1 1 5 6

7.

8.

9.

10.

11.

12.

13.

14.

15.

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B. FAMILY STRUCTURE ______Caretaker/ free
1. Type of family structure ______Rented
______ Extended ___/__Owned
______Single parent 3. Ownership status of the lot in which your house is
______Blended built
___/___Nuclear ______Squatter
______Foster parent ______Caretaker
______Rented/ Leased
2. Family Decision-maker ______Common property with other family members
__/ __Father ____/__Owned
______Mother
______Both 4. Type of Dwelling unit/structure
______Others; Please specify ____/__Permanent (concrete)
_________________________ ______Semi-permanent (wood)
_ ______Temporary (nipa hut)
______Makeshift

5. Number of Bedrooms
C. SOCIO-ECONOMIC PROFILE ______ 5-6
1. Religion ___/__ 3-4
___/___Catholic ______ 1-2
______Protestant/ Independiente ______ Others; Please specify
______Jehovah’s Witness
______Mormons
______Iglesia ni Cristo 6. Availability of Private Vehicle at home
______Born Again Christian ___/__Yes
______7th day Adventist ______ No
______Others; Please specify
__________________________

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2. Ownership status of your house

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 D. ENVIRONMENTAL HEALTH ___/___2. Open shelves
___ __3. Refrigerator
1. Availability of common garbage bin ______4. Others: ________________
inside the house
___/__Yes ____/___close 5. Drainage system
________open ______No ______1. Not available
______2. Open
__/ __3. Blind
2. Source of drinking water
______Dug well 6. Toilet facilities
___/__Commercial water ______1. Not available
______ Shared tube/pipe ______2. Open pit
______Own use tube/ pipe ______3. Closed pit
______ Shared faucet, community ___/__4. Water-sealed, shared with other households
water system ______5. Water-sealed, used exclusively by the
______Owned use faucet, community household
water system ______6. Flush toilet
______Others; Please specify
__________________________ 7. Garbage disposal
_____1. Municipal garbage collection
3. Drinking Water storage ___/__2. Communal pit
______1. Tank ______3. Open dumping
__/ ___2. Drum/ can ______4. Burning
______3. Earthen jars/pots ______5. Composting
______4. Plastic containers ______6. Others:___________
______5. Electric powered
dispenser 8. Observance of garbage segregation
______6. Others: ___/__1. Yes
________________ ______2. No

4. Food storage E. FAMILY HEALTH ORGANIZATION

______1. Cabinet

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1. Number of Alive Children ________ 1
________ 1 ________ 2
________ 2 ________ 3
________ 3 ____N/A___ 4. Others
____/ ___ 4. Others
Causes of Death:
2. Number of Deceased Children 18 ______________________
years old and below
3. Common illnesses of Children in the family (within the last 2 B. Artificial methods:
years) ________4. Condom
________________N/A_________________ ________5. Intra-Uterine Device (IUD)
________6. Pills
4. Common illnesses of the elderly in the family (within the last 2 ___N/A__7. Injectables (DEPO) years), write NA if not
applicable
__________________Hypertesion ____________ C. Surgical methods
________8. Ligations (BTL)
________9. Vasectomy
5. Children Immunizations( for children 0-18 months only) Others: _________N/A________

Type of Immunizations
NAME AGE BCG POLIO DPT HEPA MMR
(OPV) B 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: ________________

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6. Family Planning Acceptor

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________1. If Yes, Indicate age
___/ ___2. No F. Covid 19 Pandemic Status

A. How does your family prevent from being infected with

A. Natural Methods Covid 19? You may check as more than 1 answer.
___/____1. Withdrawal ________1. Wear mask when they go outside the house
________2. Abstinence ____/___2. Wear facemask and face shield when they go
________3. Calendar method outside the house
________3. Take vitamins everyday
____/___4. Stay at home ________4. Physical
___/___5. Perform hand hygiene often
_______6. Sanitize the house
____ ___7.Physical exercises ex. Zumba E. How do you deal with this aspect that is affecting
_______8. Eat healthy foods ex. Low fat, low salt, low sugar your family most?
________1. Ask for help from the government/government
B. Where do you get information to prevent Covid 19? agencies
____/ ___1. Television __/_____2. Ask for help from the relatives
___/____ 2.Radio ________3. Ask for help from employer
________ 3. Newspapers ___ ____4. Ask for help from friends
_______ 4. Internet ________5. Others; _____________________________

C. How do you rate your family coping with the Covid 19 F. How long do you think the pandemic will lasts?
pandemic in a scale of 1-10, where 10 is highest? ____/ ___1. One year
________2. Two years
_____5_______ ________3. Three years
________4. Others:_____________________________
D. What aspect of your current family status in the Covid 19
pandemic is affecting most?
___/____1. Financial
___/____2.Socio-emotional

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____ ___3. Spiritual

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