FAR EASTERN UNIVERSITY

Institute of Nursing
Community Health Survey Tool

Head of the Family:_____________________________ Control No. __________

(kinikilalang puno ng pamilya)
Complete Address: __________________________________________ No. of Family/families :___________
(Tirahan) (Bilang ng Pamilya)
Length of Residency:_________________________________________ Surveyed by :____________________________
(Tagal ng paninirahan sa lugar) (Pangalan ng Nag-survey)
Place of Origin: _________________________________ Date :____________________
(Lugar na pinagmulan) (Petsa)
Ethnic Background: ______________________________
(Etnikong grupo na kinabibilangan)
Primary Dialect Spoken: __________________________
(Pangunahing Dialektong ginagamit)

COMMUNITY AS A PEOPLE

Family Structure, Characteristics and Dynamics

Education Occupation
No. Name of Relationship (Edukasyon) (Hanap Buhay)
(Blg.) Household to the head Highest Educational
Member(s) of the Sex Date of Birth Age Civil Religion Educational Status Place Type Occupational
(Pangalan ng family (Kasa- (mo., day, (Edad) Status (relihi Attainment (Antas ng (Lugar) (Uri) Status
myembro ng (kaugnayan rian) yr.) (Estado -yon) Pinaka-mataas Edukasyon) (Kalagayan ng
pamilya) sa puno ng (kapangana- Sibil) na Antas ng Trabaho)
pamilya) kan) Edukasyong
natapos

LEGEND: M – male S – Single C- Catholic EG – Elementary Graduate NF – No Formal Education E – Employed

F - female M – Married P – Protestant EU – Elementary Undergrad. PS – Presently Studying U – Unemployed
W – Widowed SA – 7th Day Adventist HG – High School Grad SS – Stopped Studying
CL – Common Law INC – Iglesia ni Cristo HU - High School Undergrad. C – College Grad
Sep – Separated JW – Jehova’s Witness CU – College undergrad
V - Vocational
 COMMUNITY AS A SOCIAL SYSTEM
A. Economic Aspect

13. Combined Monthly family income (Buwanang kita ng pamilya) 18. Community Program
(Ano ang mga alam na programa sa komunidad)
( ) P1,000 and below ( ) P10,001 – P15,000 ( ) P25,001 – P30,000
( ) P1,001 – P5,000 ( ) P15,001 – P20,000 ( ) P30,001 and above ____ aware _____ unaware
( ) P5,001 – P10,000 ( ) P20,001 – P25,000
( ) peace and order ( ) fumigation ( ) curfew
14. Other sources of Income (livelihood) ( ) tapat ko linis ko ( ) sportfest
( ) others, pls. specify ______________
(Mayroon pa bang ibang pinagkukunan ng kabuhayan?)
( ) Yes ( ) No 19. Predominant Organizations in the community
If yes, what? (kung mayroon, ano ito?) (Kilalang samahan sa komunidad)
( ) sari-sari store ( ) poultry raising ( ) livestock raising
( ) craft making ( ) Others {pls. specify}________________ ( ) Barangay Council ( ) Sangguniang Kabataan
( ) Couples for Christ ( ) Seniors Citizens Club
14. Monthly family expenditure (Buwanang gastusin ng pamilya) ( ) other, pls. specify _________________________

( ) P1,000 and below ( ) P10,001 – P15,000 ( ) P25,001 – P30,000 _____ member _____ non - member
( ) P1,001 – P5,000 ( ) P15,001 – P20,000 ( ) P30,001 and above
( ) P5,001 – P10,000 ( ) P20,001 – P25,000 20. Traditions celebrated/ observed in the community
(Tradisyong idinaraos/ ipinagdiriwang sa komunidad)
15. Priority Expenditure, rank it 1 – 7 (1 is the highest; 7 is the lowest)
( ) Fiesta ( ) Holy Week
____ food (pagkain) ____ health (kalusugan) ( ) others, pls. specify ______________________________
____ house rental (upa sa bahay) ____ education (edukasyon)
____ electric bill (bayarin sa kuryente) ____ clothing (damit) C. Environmental Aspect
____ water bill (bayarin sa tubig)
21. Land Ownership (Pagmamay-ari ng lupang tinitirahan)
16. Resources allotted for health care .
(Nakalaang pondo para sa kalusugan) ( ) owned ( ) rented ( ) lease to own ( ) rent free

( ) Yes ( ) No 22. House Ownership (pagmamay-ari ng bahay na tinitirhan)

If yes, from where? (kung oo, galing saan?)
( ) Health Insurance ( ) SSS/GSIS ( ) owned ( ) rented ( ) lease to own ( ) rent free
( ) Phil Health ( ) savings
( ) others, please specify ________________ 23. Type of Materials Used for house (Uri ng Materyales ng bahay)

B. Political / Leadership Aspect ( ) light ( ) strong ( ) mixed ( ) makeshift (barong barong)

17. Recognized leaders in the community
(unang taong kinukunsulta at kinikilalang pinuno ng komunidad) 24. Ventilation

( ) Barangay Officials ( ) religious leaders ( ) elders ( ) well ventilated ( ) fair ( ) poorly ventilated
( ) Non- government organizations ( ) others, pls. specify ____________ (requirement: opening 10% of floor area)
25. Lighting – facilities 33. Storage of drinking water (Imbakan ng inuming tubig)

( ) electricity ( ) kerosene ( ) candles ( ) Jar (banga) ( ) plastic/glass container

( ) others, pls. specify ___________________ ( ) bottles ( ) drum
( ) water tank ( ) water dispenser
____ adequate ____ inadequate _____ covered _____ uncovered

26. Excreta Disposal ( Uri ng Palikuran) 34. Method commonly used in sanitizing water
(Paraang ginagamit upang mapanatiling malinis ang inuming tubig)
( ) pail system ( ) open pit privy
( ) flush type ( ) Antipolo type ( ) boiling (pagpapakulo)
( ) bored hole latrine ( ) closed pit privy ( ) filtration (pagsasala
( ) overhung latrine ( ) water – sealed latrine ` ( ) sedimentation (pagpapalatak)
( ) others, pls. specify __________________________
27. Ownership of Toilet Facility (pagmamay-ari ng palikuran)
35. Domestic animals upkeep (dogs and cats only)
( ) private (sariling gamit)
( ) shared (may kahati sa gamit)
( ) public (gamit pambayan) Kind Number Place kept Vaccination (Bakuna sa hayop)
(Uri) (bilang) (pinaglalagyan With (mayroon) Without (wala)
28. Sewerage System in the community ( Uri ng kanal sa komunidad) )

( ) blind drainage ( ) open drainage ( ) none

29. Condition ( kalagayan ng daloy ng tubig sa kanal)

36. Present of vectors and rodents (pagkakaroon ng peste sa bahay)
( ) free flowing ( ) stagnant ( ) flies (langaw) ( ) termites (anay) ( ) rats (daga)
( ) roaches (ipis) ( ) mosquitoes ( lamok)
30. Type of waste disposal used (Uri ng pagtatapon ng basura) ( ) others, pls. specify __________________________

( ) animal feed ( ) composting 37. Presence of breeding sites of vectors ( pagkakaroon ng lugar na
( ) open dumping ( ) burial pit pinamamahayan ng mga peste)
( ) burning ( ) garbage collection (DPS)
( ) others, pls. specify __________________________ ____ with ____ without
if with, pls. specify location _______________________
31. Container used for garbage
38. Ways of controlling vectors (Paraang ginagawa upang mapuksa ang mga
( ) garbage bag ( ) waste basket ( ) sack ( ) none peste sa bahay)
____ covered ____ uncovered
( ) fumigation (pag-papa-usok) ( ) insecticides ( pmatay insekto)
32. Source of drinking water (pinanggagalingan ng inuming tubig) ( ) fly traps ( ) mouse traps
( ) screens on doors and windows
( ) commercially prepared water ( ) deep well ( ) others, pls. specify _____________________________________
( ) local water system ( ) rain water
 ( ) artesian well ( ) streams, rivers or spring

D. Health Aspect

39. Community health programs (programang pangkalusugan) Aware Utilizes 43. Medications taken during illness (Gamot na iniinom)
(Alam) (nagkukunsulta)
( ) Free consultation (libreng konsulta) ______ _______ ( ) prescribed ( ) herbal ( ) over the counter

( ) Immunization (libreng Bakuna) ______ _______ ( ) others ( Pls. Specify) _____________________

( ) Family Planning (Programa sa pagpapaplano ng pamilya) ______ _______
( ) Pre-natal Check up (programa para sa buntis) ______ _______
( ) well-baby clinic (konsulta para sa mga sanggol at bata) ______ _______
( ) Others (Pls. Specify) ____________________________ ______ _______

44. Method of Family Planning (Pagpaplano ng pamilya)

Name Age Acceptor Non-

Acceptor

40. Food usually eaten. (Madalas ng kinakain) A. Natural

( ) Fish ( ) Meat ( ) Vegetable ( ) Mixed ( ) rhythm ( ) cervical mucus method ( ) withdrawal

41. Food storage practices. (Pangangalaga sa pagkain) ( ) Basal body temperature ( ) others (specify) ____________

( ) refrigerator ( ) table ( ) basket ( ) others B. Artificial contraceptives

____ covered ____Uncovered ______________ ( ) condoms ( ) IUD ( ) pills ( ) others __________

42. First person consulted in times of illness (Unang taong kinukunsulta tuwing C. Permanent
may nagkakasakit) ( ) vasectomy
( ) doctor ( ) albularyo ( ) midwife ( ) relatives ( ) tubal ligation
( ) nurse ( ) faith healer ( ) family
( ) BHW ( ) hilot ( ) others (pls. specify)______________
 • For items 45 – 48: Answer only if applicable
o 46 and 47 – If there are children 0 – 12 months in the family
o 48 – if there are children 0 – 83 months (0 – 7 yrs) in the family
o 46 – if there is a pregnant member of the family

45. Infant Feeding Program

( ) Breast Milk ( ) Commercially Prepared Milk ( ) Mixed

Commercially Prepared::

_____ Condensed Milk _____ Evaporated Milk

_____ Powdered Milk _____ Others (please specify) ________________

46. Maternal Care (Pangangalaga sa mga buntis)

Name No. of Age of Gestation Expected Date of PreNatal Check - Up Tetanus Toxoid Immunization
(Panganlan) Pregnanc (Bilang ng buwan Delivery (Inaasahang with without with without
y ng pagbubuntis) petsa ng panganganak)

47. Immunization Status of Target Age Group (0 – 12 months)

Name Age in BCG DPT OPV Hepatitis B AMV Remarks

Mos.
1 2 3 1 2 3 1 2 3 incomplete complete Fully Immunized
48. Nutritional Status for Children (0 – 83 months)

Name Date of Weighing Date of Birth Age ( in Weight Remarks

(Pangalan) (Petsa ng (Kapanganakan) months) (Bigat)
Pagtimbang) (Edad)

49. Morbidity

Name Intervention
(Pangalan) Age Sex (Medication)
(Edad) (Bigat)
With Without

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