Community Health Assessment Form Respondent: Stage: Relation to Head (if not head of the Family): I.

Family Data A. Head of the Family: B. Name of Spouse C. Address D. Educational Attainment i. Husband ii. Wife E. Length of Residency: F. Ethnic Origin: G. Family ( ) Nuclear ( ) Extended H. Religion: I. Number of Children: J. Members of the Household NAME AGE SEX Age: Sex:

Age: Age:

EDUCATION

OCCUPATION

II. Socio-Economic Data A. Source of Income Occupation Husband: Wife: Garbage Collector; part of Recyclers Association Employed ( ) Unemployed ( ) Self-Employed ( ) Monthly Income Below P2000 ( ) P2,000-P5,000 P5,001 P8, 000 ( ) more than P8,000 B. Family expenditures 1. Food Below P50 ( ) More than P70 ( ) 2. Clothing: number of times buying Once ( ) Thrice ( ) 3. Housing Water ( ) Telephone ( ) 4. Schooling Public ( )

( ) ( )

P50 75

( )

Twice

( )

Electricity

( )

Private

( )
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5. Others: III. Housing and Environmental Conditions A. Home Type Concrete Mixed Others: Ventilation: Poor Lighting Adequate Surroundings Clean

( ) ( )

Wood Makeshift

( ) ( )

( ) ( ) ( )

Good Inadequate Dirty

( ) ( ) ( )

B. Source of Water Supply Artesian Well NAWASA ( )

( )

Deep well Others:

( )

C. Storage of Drinking Water Refrigerated Uncovered ( ) Containers used: Plastic Bottles D. Toilet Facilities Sanitary: Flush Shared Others: Unsanitary: Ballot System E. Garbage Disposal Collection Burying Garbage Cans F. Food Storage Covered Refrigerated G. Presence of Animals Dogs Pigs

( )

Covered

( )

( ) ( )

Clay Jars Others:

( )

( ) ( )

Pit privy Owned

( ) ( )

( )

Others:

( ) ( ) ( )

Burning Open Dumping Others:

( ) ( )

( ) ( )

Uncovered

( )

( ) ( )

Cats Others:

( )

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H. Backyard Gardening Vegetables Fruit-bearing IV. Community Resources A. Health and Other Facilities Health Center School Church

( ) ( )

Herbal

( )

( ) ( ) ( )

Barangay Hall Park Market

( ) ( ) ( )

B. Indigenous Health Workers Trained Hilot ( ) Herbularyo ( ) Others: C. Sources of Health Funds Government NGOs/Pos V. Nutrition A. Food Preferences Fish Meat

BHW Untrained Hilot

( ) ( )

( ) ( )

Private Others:

( )

( ) ( )

Fruits/vegetables ( ) mixed

( )

B. Common Fare Rice and egg Rice and noodles

( ) ( )

rice and sardines ( ) others:

C. Presence of Nutritional Disorder Goiter Enlargement of neck ( ) Hoarseness ( ) Anemia Pallor ( ) Body Weakness ( ) Vitamin A deficiency Night blindness ( ) Others:

dysphagia Others: Easy fatigability

( )

( )

Pilaksamata

( )

VI. Knowledge, Attitude and Practice A. Do you utilize the health center? Yes ( ) If no, why? B. Reason Illness Family Planning Dental

No

( )

( ) ( ) ( )

Prenatal Postnatal Nutrition

( ) ( ) ( )
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Immunization

( )

C. First person consulted in times of illness M.D. ( ) Nurse Midwife ( ) Hilot Herbularyo ( ) BHW Others: D. Usual Illness in the Family

( ) ( ) ( )

What do you do for this condition? Self Medication ( ) Consultation Hospital ( ) Private Clinics Nursing ( ) Others: E. Other Diseases TB ( ) Leprosy Skin diseases ( ) Hepatitis ( ) Others: heart disease and cancer F. Do you submit your children (0-12 months) for immunization? Name of Child Birthday BCG DPT OPV

( ) ( )

( )

AM

G. Do you practice family planning? Yes ( ) No Method: If no, why? H. Method of Infant Feeding Breast Mixed

( )

( ) ( )

Bottle

( )

I. Subjects you want to learn in health education: no specific Drug abuse ( ) Nutrition ( ) Family Planning ( ) Herbal Plants First Aid Measures ( ) Others:

( )

Interviewed by: Date: Time:

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