COMMUNITY HEALTH ASSESSMENT FORM

Respondent: _____________________________________________ Age: _________

Stage: ________________________________________________ Sex: _________
Relation to Head: _______________________________________ (if not the head of the family)

FAMILY DATA
Members of the Household
Name Relation to the Head Age Sex Status Religion

Address: ______________________________________________________________________
Telephone Number: _________________________
Length of Residency: ________________________
Ethnicity: _________________________________
Family: ( ) Nuclear ( ) Extended ( ) Others (specify) ___________________
Family Size: ( ) Small (1-4) ( ) Medium (5-8) ( ) Large (7 & up)
Number of Children: ________________________
Making decision about financial matters
( ) Father ( ) Mother ( ) Both ( ) Children

SOCIO-ECONOMIC DATA
Source of Income
Name Employment Type of Place Monthly Educational
Status Work Income Attainment

Basic Expenditures
Allocation of biggest budget
( ) Food ( ) Clothes ( ) House ( ) Others (specify) _____________
Food Daily
( ) below 50 ( ) 50-100 ( ) more than 100
Clothing: Number of times buying in a year
( ) Once ( ) Twice ( ) Thrice ( ) More than three times a year
Housing
( ) Water ( ) Electricity ( ) Telephone
Schooling
( ) Public ( ) Private

HOUSING AND ENVIRONMENTAL CONDITION

Home
( ) Concrete ( ) Wood ( ) Mixed ( ) Makeshift
Ownership
( ) Owned ( ) Rented ( ) Rent-free
( ) Single attached ( ) Single detached ( ) Two storey
Number of rooms for sleeping: ________________________________
Ventilation: ( ) Poor ( ) Good
Lighting Facilities: ( ) Electricity ( ) Kerosene
General Surroundings: ( ) Clean ( ) Dirty
Sanitary observations: ___________________________________________________________
Presence of accident/hazards
( ) Broken stairs ( ) Fall hazards ( ) Sharp objects ( ) Fire hazards
Scheduling/Frequency for house cleaning: ___________________________________________
Source of Water Supply: ( ) Artesian Well ( ) Deep Well ( ) NAWASA
Storage of drinking water: ( ) Refrigerated ( ) Covered ( ) Uncovered
Kitchen: ( ) Electric Stove ( ) Gas stove ( ) Firewood/Charcoal
Drainage: ( ) Open ( ) Blind ( ) None
Sanitary observations: ___________________________________________________________
Containers used: ( ) Plastic ( ) Jars ( ) Bottles
Toilet Facilities (Sanitary) ( ) Flush ( ) Pit privy
( ) Owned ( ) Shared
(Unsanitary) ( ) Balot System
Waste Disposal: ( ) Collection ( ) Burning ( ) Burying
( ) Open Dumping ( ) Garbage Cans
Food Storage: ( ) Covered ( ) Uncovered ( ) Refrigerated
Presence of animals: ( ) Dogs ( ) Cats ( ) Pigs
Backyard gardening: ( ) Vegetables ( ) Herbal ( ) Fruit-bearing
Communication and Transport Facilities
Communication: ( ) Telephone ( ) Mobile Phone
Transportation: ( ) Owned Private Car
( ) Public Utility Vehicle
___ MRT/LRT ___ Jeepney ___ Bus ___ Tricycle

Community Observations
Sanitary conditions: _____________________________________________________________
House overcrowding/congestion: ( ) Yes ( ) No
Presence of breeding sites of vectors: ( ) Yes ( ) No
If yes, please specify: ____________________________________________________________
Health facilities: ________________________________________________________________
Recreational facilities: ___________________________________________________________
Distance of house to the nearest health care facility: ___________________________________

COMMUNITY RESOURCES
Health and other facilities
( ) Health Center ( ) Barangay Hall ( ) School
( ) Church ( ) Park ( ) Market
Indigenous health workers
( ) Trained hilot ( ) Untrained hilot ( ) Albularyo ( ) BHW
Sources of health funds
( ) Government ( ) Private ( ) NGOs/Pos

NUTRITION
Nutritional Assessment
Dietary Intake (Number of times daily): ______________________________________________

Food Source How often is it served or consumed weekly?

Fish
Meat
Fruits
Vegetables
Canned food
Carbonated drinks (soft drinks)
Amount of water intake daily: __________
How often do you eat at fast food places? ( ) Once ( ) Twice ( ) More than 3 times
Common pair: ( ) Rice and Egg ( ) Rice and Sardines ( ) Rice and Noodles
Dietary supplements: ( ) Vitamins ( ) Food supplements
Presence of nutritional disorder
Goiter
( ) Neck enlargement ( ) Dysphagia ( ) Hoarseness of voice
Anemia
( ) Pallor ( ) Easy fatigability ( ) Body weakness
Vitamin A deficiency
( ) Night blindness ( ) Pilak sa mata
Presence of faulty eating habits: ( ) Skipping meals ( ) Too much salty/sweet food
( ) Starving oneself ( ) Eating before bedtime

KNOWLEDGE, ATTITUDE, PRACTICE

Do you utilize the health center? ( ) Yes ( ) No
If not, why? ______________________________________________________________
Reason for visiting the health center
( ) Illness ( ) Family planning ( ) Dental
( ) Prenatal ( ) Postnatal ( ) Nutrition
Common diseases in the family:
____________________________________ ___________________________________
____________________________________ ___________________________________
____________________________________ ___________________________________

What do you do for this condition?

( ) Self medication ( ) Hospital ( ) Consultation
( ) Nursing ( ) Private clinics
First person consulted in times of illness
( ) MD ( ) Midwife ( ) Herbularyo
( ) Nurse ( ) Hilot ( ) BHW
Risk factors of lifestyle diseases
( Smoking ( ) Alcoholism ( ) Obesity
Other diseases
( ) TB ( ) Skin disease ( ) Leprosy ( ) Hepatitis
Immunizations
Age Type of Immunization Place of Delivery Birth attendant

RESPONSIBLE PARENTHOOD
Family Planning: ( ) Yes ( ) No
Method used: ( ) Hormonal ___ Pills ___ Injectables ___ Implants
( ) Natural ___ Calendar ___ Cervical Mucus ___ BBT
( ) Barriers ___ IUD ___ Condom ___Diaphragm
( ) Surgical ___ Ligation ___ Vasectomy
Pregnancy (currently): ( ) Yes ( ) No
Prenatal check-up
When: ____________________________________________
Where: ___________________________________________
Method of infant feeding: ( ) Breast ( ) Bottle ( ) Mixed
HYGIENIC PRACTICES
Activity Frequency
Bathing
Combing of hair
Cleaning of ears
Brushing of teeth
Trimming of nails
Changing of clothes/underwear

Rest and Sleep: ( ) Adequate ( ) Inadequate

Number of hours of sleep: _____________________________
Exercise/Relaxation/Other lifestyle activities: ( ) Adequate ( ) Inadequate
Activity Frequency

Protective Measures
( ) Footwear ( ) Bed nets ( ) Mosquito repellent ( ) Umbrella
Subjects you want to learn in health education
( ) Alcohol and drug abuse ( ) Smoking ( ) Herbal medicine
( ) Nutrition and physical activity ( ) Hygiene and Sanitation ( ) Emotional wellness

Interviewed by: _________________________________________________________________

Date: ____________________________________ Time: ___________________________