COMMUNITY HEALTH SURVEY FORM

Head of the Family:_____________________________________ House No.:____ Date Assessed:_______

No. Family Member Name Relation to Head Sex Age Marital Status Educational Attainment Occupation Monthly Income

No.

NAME

CHILDRENS IMMUNIZATION AGE SEX BCG DPT

OPV

HEPA B

MEASLES

1. Type of Family: [ ] Nuclear [ ] Extended [ ] others, specify: ____________ 2. Home: Ownership: [ ] Owned [ ] Rented [ ] others, specify: ____________ Construction materials used: [ ] Wood [ ] Mixed [ ] Concrete [ ] others, specify: ___________ Numbers of rooms used for sleeping: _______ Lighting Facilities: [ ] Electricity [ ] Kerosene [ ] others, specify: ____________ General Surroundings: [ ] Clean [ ] Dirty 3. Water Supply: Source: [ ] Artesian well [ ] Deep well [ ] MAWASA [ ] others, specify: ____________ Storage of Drinking Water: [ ] Covered [ ] Uncovered [ ] Refrigerated [ ] others, specify:______ Sanitary Condition: ____________________ Kitchen: Cooking Facility: [ ] Electric Stove [ ] Gas Stove [ ] Firewood/Charcoal Sanitary Condition: ______________ Drainage Facility: [ ] Open [ ] Blind [ ] None 4. Domestic Animals KIND NUMBER WHERE KEPT

5. Pest / Insect: [ ] Mosquito

[ ] Lizards

[ ] Flies

[ ] others, specify:_____

6. Garbage Disposal Container: [ ] Covered [ ] Open [ ] None Method of Disposal: [ ] Hog Feeding [ ] Open Burning [ ] Open Dumping [ ] Garbage Collection [ ] Burial in Pit [ ] Composting [ ] others, specify: _____________ 7. Toilet Facility Sanitary: [ ] Flush Type [ ] Pit Privy / Communal ( ) with septic tank Ownership: [ ] Owned [ ] Shared Unsanitary: [ ] Ballot System [ ] others, specify: _____________ 8. Nutrition Food Preference: [ ] Meat [ ] Fish [ ] Fruits/Vegetables [ ] Mixed Common Food: [ ] Rice and Egg [ ] Rice and Noodles [ ] Rice and Sardines [ ] others, specify: ______________ 9. Food Storage [ ] Covered [ ] Uncovered [ ] Refrigerated [ ] others, specify: _________ 10. Gardening [ ] Fruit Bearing [ ] Vegetables [ ] Herbal [ ] others, specify: ________________ 11. Whom do you consult in time of illness? [ ] Private [ ] Rural Health Midwife [ ] Traditional, e.g. Herbularyo [ ] Others, specify: ______________ 12. Common illness encountered within 6 months: [ ] Malaria [ ] Amoebiasis [ ] Influenza [ ] Dengue Fever [ ] Tuerculosis [ ] Asthma [ ] Typhoid Fever [ ] others, specify: __________ 13. Plan to utilize Health Service: [ ] Hospital [ ] Health [ ] Clinic [ ] others, specify: ____________ 14. Do you utilize your Health Center? [ ] Yes [ ] No 15. Reasons for utilizing Health Center: [ ] Post Natal [ ] Pre Natal [ ] Immunization [ ] Morbidity [ ] Health Counselling [ ] others, specify: ______________ 16. Environment Kind of Neighborhood Social and Health Facilities Available Communication and Transportation Available Assessed by:

________________________________ Students Signature over Printed Name

Noted by:

GLORIA N. RAMOS, M.A.N Clinical Instructor