Community Health Survey 1
Community Health Survey 1
Community Health Survey 1
COLLEGE OF NURSING
I.SOCIO-ECOMNOMIC-DEMOGRAPHIC-CULTURE DATA
A.FAMILY STRUCTURE & SYSTEM
Education
Approx.
Sex al Source of
Name of Family Members Position Age CS Religion Nationality Monthly
/LGBT Attainme Income
Income
nt
HUSBAND 73 M M ROMAN HIGSCHO FILIPINO PENSION 22K
ADOLFO CAPEDING CATHOLIC OL LEVEL
APOLONIA CAPEDING WIFE 70 F M ROMAN COLLEGE FILIPINO PENSION 19K
CATHOLIC GRAD.
a. Family size: 2
1
B.SOCIO-ECONOMIC CHARACTERISTICS
a. Type of Community: Rural Urban
b. Membership in Civic/Community Organizations
Member: Position/Role: BRGY. COUNCILOR Name of Organization: BRGY. COUNCIL
Non-member:
c. Describe the involvement of the family in Community Organizations:
“Pagtuman san pagkinahanglanon san barangay ngan maimplementar sin tadong ngan sadang”
d. Values being uphold by the family among the members
“Pagrosaryo kada kulop” “ Dudrungan nga pangaon namon nga mag asawa”
e. Beliefs and Practices
HEALTH FAMILY MANAGEMENT
Beliefs Practices Beliefs Practices
Insulin Plant “Ginhuhgasan katima hugas
sin maupay pwede mo siya
kisamon”
Ashitaba “Ginhuhgasan katima hugas
sin maupay pwede mo siya
kisamon”
C. POLITICAL
II. HEALTH
A. Immunization Status (Family with 0-59 mos.►start from eldest)
Where the Vaccine Received
Date of
Name of Child Age Immunization
Birth BCG DPT1,DPT2,DPT3 OPV Measles Others
was received
B. for Family with 0-11mos., indicate date when child becomes fully immunized
Month ______ Day _______ Year _______
C. for Family with 12-59mos., indicate date the child was given Vit. A
Month ______ Day _______ Year _______
2
F. Enumerate common causes of sickness in the family, (Morbidity) in the past year.
H. If a member of the family died in the past year, what was the common cause of death? (Mortality) Specify.
HILARIA FERREZ (aunt) cause of death- Old Age
I. For a family with 0-59 mos. old child, who attended the delivery of the mother?
Doctor Midwife Untrained Hilot (TBA)
Nurse Trained Hilot
J. Does the mother visit RHU or BHS for prenatal check-up?
YES/NO: SPECIFY WHERE:
LMP: EDC: AOG: BLOOD TYPE:
K. In most of her deliveries, where does the mother deliver her baby?
Hospital Date delivered: ___________________
Home 0-42 days: _______________________
Maternity Clinic
L. Tetanus Toxoid Vaccination of Woman of reproductive age (15-49y.o)
For mother/wife Total Tetanus Toxoid Status
Name Age CS
Pregnant? Not pregnant? Pregnancy TT1 TT TT3 TT TT
Want to add
Yes children?
No Yes
No
Yes
No
if unsure, advise to visit the RHU
Others:
3
Name Age Birthday Date weighed Actual Weight Status
A.DRINKING WATER
a. Water supply or source of drinking water (check the box)
Protected well Open dug wells (level 1)
Developed Spring (level 1) Unimproved Springs (level 1)
Communal Faucet (level 2) Individual House Connection
(level 3)
Tank (level 2)
4
B.EXCRETE DISPOSAL
With toilet Unapproved Type
Approved Type Antipolo Type
Pit Latrines Cathole
Pour flush toilet
WST/Flush type
Without toilet
C.SEWAGE DISPOSAL
Open drainage Blind Drainage
D.GARBAGE DISPOSAL
Burning Incineration Dumping in Land
Burying Placed in compost pit Dumping in river banks/seashore
E.FOOD STORAGE
Covered plated Covered plastic or food container (Tupperware)
Cabinets Refrigerator
F.GARDENS
Herbal Fruits
Flower Vegetables
G.AIR POLLUTION
Industrial plants/factories in the Barangay
Presence of cars/automobiles which emit gas/fumes
Smoker in the family
H.RECREATIONAL FACILITIES
Playground
Theater
Others, specify ____________________________
I.PRESENCE OF HEALTH HAZARDS IN THE COMMUNITY
None
Yes, specify ___________ ____________________________
J.PRESENCE OF INSECTS/RODENTS
None
Yes, specify ____________________________
K.PRESENCE OF STRAY ANIMALS
None
Yes, specify DOG Tied: Fenced
IV.COMMUNITY NEEDS AND PROBLEMS AS PERCIEVED BY THE FAMILY/SUGGESTION TO SOLVE THE ROBLEM