MARIANO MARCOS STATE UNIVERSITY

City of Batac, Ilocos Norte

COLLEGE OF MEDICINE

Community Diagnosis Survey Tool

Head of the Family: _________________________________________ Control No. ______

Complete Address: _________________________________________ No. of family members: _________
Length of Residency: _________________________________________ Surveyed by: ________________________
Place of Origin: ______________________________________________ Date: __________________________
Ethnic Background( Indeginous group): __________________________
Primary Dialect/Language Spoken: _____________________________
Type of Family : ( ) Nuclear ( ) Extended Others please specify: __________

A. COMMUNITY AS A PEOPLE
Family Structure, Characteristics and Dynamics
NO.
EDUCATION OCCUPATION
RELATIONSHIP TO THE CIVIL
NAME OF HOUSEHOLD MEMBERS AGE/ SEX DATE OF BIRTH RELIGION HIGHEST TYPE
HEAD OF THE FAMILY STATUS EDUCATTIONAL OCCUPATIONAL
(INDICATE THE
EDUCATIONAL PLACE
STATUS SPECIFIC STATUS
ATTAINMENT OCUPATION)

1 Head of the family

2
3
4
5
6
7
8
9
10

LEGEND:
Sex Civil Status Religion Highest Edu. Attainment Educational Status Occupation (place)
M male S Single C Catholic *Indicate level for Undergraduates (ex. EU3) PS Presently Studying IN w/in the community
F female M Married (church/jugde) P Protestant EG Elementary Graduate SS Stopped Studying OUT outside community
W Widowed SA 7th Adventist EU Elementary Undergraduate Note for out of school
CL Common Law INC Iglesia ni Cristo HG High School Graduate youth. (OSY 7-20 yrs. old Occupational Status (15-64 y/o)
Sep Separated JW Jehovas Witness HU High School Undergraduate stop studying) E Employed
N/A (0-14 y/o) BA Born Again C College Graduate ER Employed Regular
(Indicate the degree finished) EC Employed Contractual
CU College Undergraduate U - Unemployed
V Vocational SE Self Employed
US Under School age (under 5 yrs.)
NF No formal Edu. (6 yrs. Above)
B. COMMUNITY AS A SOCIAL SYSTEM

1. Primary mode of transportation 8. Resources allotted for Health Care

[ ] Tricycle [ ] Bicycle [ ] Jeep Others please specify: ___________ [ ] Yes [ ] No

*If yes, from where?
2. Primary mode of Communication [ ] Health Insurance
[ ] SSS/GSIS
[ ] Telephone [ ] E-mail Others please specify: ___________ [ ] Phil. Health
[ ] Cell phone [ ] Two-way radios [ ] Savings

3. *Recognized Key Person D. ENVIRONMENTAL ASPECT

[ ] Barangay Captain [ ] Elderly [ ] Religious Leaders 9. Land Ownership

[ ] Kagawad [ ] BHW Others please specify: ___________
[ ] Owned
C. ECONOMIC ASPECT OF THE COMMUNITY [ ] Rented
[ ] Lease to own
4. Combined Monthly Family Income [ ] Rent Free

[ ] 5,000 and below [ ] 15,001 - 20,000 10. House Ownership

[ ] 5,001 10,000 [ ] 20,001 25,000
[ ] 10,001 15,000 [ ] 25,001 30,000 [ ] Owned
[ ] 30,001 and above [ ] Rented
[ ] Lease to own
5. Other Source of Income/Livelihood [ ] Rent Free

[ ] Yes [ ] None *If yes, what? 11. Types of materials used for house
[ ] Light
[ ] Sari-sari Store [ ] Fishing [ ] Strong
[ ] Poultry raising [ ] Charcoal Making [ ] Mixed
[ ] Livestock raising Others please specify: ___________ [ ] Make shift

6. Monthly Family Expenditure 12. Primary Lighting-facility

[ ] 5,000 and below [ ] 15,001 - 20,000 [ ] Electricity [ ] Candles

[ ] 5,001 10,000 [ ] 20,001 25,000 [ ] Kerosene Lamp Others Please Specify: ___________
[ ] 10,001 15,000 [ ] 25,001 30,000
[ ] 30,001 and above
13. Primary Cooking Facility
7. Priority Expenditure, rank it 1-7 (1 is the highest, 7 is the lowest)
[ ] LPG [ ] Wood Others Please Specify: ___________
Food [ ] Electric [ ] Kerosene
House Rental
Electric Bill 14. Ventilation (TWO/TFA x 100)
Water Bill
Clothing [ ] 17% below poor [ ] 18% - 19% fair [ ] 20% above good
Health
Education
 15. Ownership of toilet facility 24. Food storage Practices

[ ] Private [ ] Refrigerated
[ ] Shared [ ] Non refrigerated : [ ] Covered [ ] Not covered
[ ] Public
[ ] None 25. Domestic Animals

16. Excreta disposal Animal Number Place kept Vaccination

[ ] Level 1 (Pit Latrine)

[ ] Level 2 (Septic Tank)
[ ] Level 3 (Treatment Facility)
[ ] No toilet facility Balot/Wrap System

17. Sewerage System in the Community 26.* Presence of Vectors

[ ] Blind Drainage [ ] None [ ] mosquito [ ] rat (daga) [ ] flies

[ ] Open Drainage [ ] cockroach Others please specify: ___________

18. Condition 27. Presence of breeding sites of vectors

[ ] Free flowing [ ] Stagnant [ ] None If with, please specify the location: ___________

19. Container used for garbage 28. *Ways of controlling vectors (mga paraan upang puksain ang peste)

[ ] Covered [ ] Uncovered [ ] Fumigation [ ] Setting traps

[ ] Screens on doors and windows [ ] None
20.* Type of waste management used [ ] Insecticides Others please specify: ___________

[ ] Segregating [ ] None 29. Family Practices

[ ] Composting Others please specify: ___________
[ ] Recycling Practices Practiced Not practiced
Sleep 6-8 hours a day
21. * Method of Disposal Smoking
Regular Exercise
[ ] Animal feed [ ] Burial Pit Dental Check-up
[ ] Open Dumping Others please specify: ___________ Drinking alcohol beverages
[ ] Garbage Collection Medical Check-up
Others please specify:
22. Source of Drinking water
30. Food/s usually eaten
[ ] Level 1 (point source)
[ ] Level 2 (communal) [ ] fish [ ] meat
[ ] Level 3 (water works system) [ ] vegetable [ ] mixed

23.* Method commonly used in sanitizing water E. HEALTH ASPECT

[ ] Filtration [ ] Sedimentation 31. Health seeking behavior

[ ] Boiling Others please specify: ___________
[ ] None [ ] Hospital [ ] Private Clinic
[ ] Health Center Others please specify: ___________
*Multiple Responses check more than one.
 32. Primary source of Health Information 37. For couple of Reproductive age
Are you using a method of Family Planning? If yes, what kind of method?
[ ] Hospital [ ] Mass media
[ ] Health Center Others please specify: ___________ [ ] Yes (acceptor) [ ] No (non-acceptor)

33. First person consulted in time of illness If Yes, which of the following method:
A. Natural method
[ ] Formal [ ] Informal
[ ] Doctor [ ] Faith Healer [ ] Rhythm/Calendar
[ ] Nurse [ ] Albularyo [ ] Cervical Mucus method
[ ] Midwife [ ] Hilot [ ] Basal body temp.
Others please specify: ___________
34. Primary medications taken during illnesses
B. Artificial Contraceptive
[ ] Herbal Medicines
[ ] Prescribed drugs [ ] Condoms
[ ] Over the counter drugs [ ] IUD
Others please specify: ___________ [ ] Pills (pildoras)
Others please specify: ___________
35. Health programs
C. Permanent method
Programs Available Awareness Utilized
Yes No Yes No Utilized Not Utilized [ ] Vasectomy for males
EPI (0-12 months) [ ] Tubal Ligation for females
TB-DOTS
(GP)Vit. A (6mos-7 y/o) 38. Infant feeding (0-2y/o)
(GP)Deworming (2y/o-7y/o)
Reproductive Health [ ] Breastfeeding
Pre and Post Natal [ ] Exclusive breastfeeding (birth until 6 mos.)
[ ] Complementary breastfeed (until 6 mos. and 1 day - 2 y/o)
[ ] Powdered milk
36. Morbidity [ ] Bottle feed
[ ] Am
Age Sex Major and Minor Illness Diagnosed w/ Intervention [ ] Condensed milk
Past 5 years Yes (Y) No (N) Yes (Y) No(N) [ ] Evaporated milk
Others please specify: ___________

Mortality

Age Sex Cause of Death Diagnosed w/intervention

Past 5 years Yes (Y) No (N) Yes (Y) No (N)

*Multiple Responses check more than one.

39. Immunization Status (Target age group 0-12 mos. Only)

Name Age in BCG Hep B DPT OPV AMV (9-12m) Remarks

mos. (birth) B 6 14 6 10 14 6 10 14 Complete Incomplete Fully None
Immunized

40. Nutritional Status for children (0-72 mos. Only)

A. Weight
Name Date of weighting Date of Birth Age (in mos.) Weight Remarks

Legend:
VL Very Low
L Low
N - Normal
A Above Normal

B. Height
Name Date of measurement Date of Birth Age (in mos.) Height Remarks

Legend:
S Short
N Normal
T Tall

41. Maternal Care (Pregnant Woman)

Prenatal Check-up Tetanus Toxoid
No. of Immunization
Name Age of Gestation Expected date of delivery Without
pregnancy
st nd rd
1 2 3 1 2 3 4 5

42. Place to deliver the baby

[ ] Home
[ ] Lying-in
[ ] Hospital

Signature of the Surveyor