Survey

Name: ________________________________________
Age:____ Weight/Height ________
Address:_____________________________________________________________________
Religion:___________________

INTEGUMENTARY
Skin
uniform in color __ yes __no
presence of blemishes __yes __no
skin turgor __good __poor
foul odor __yes __no
temperature ________
Hair
hair color ______________
silky hair __yes __no
evenly distributed __yes __no

Nails
shape __convex __concave
smooth __yes __no
capillary refill ___________

HEAD
Head
shape ____________
Skull
nodules __yes __no

Face
consistency __yes __no
nodules __yes __no

EYES AND VISION

Eyebrows
evenly distributed hair __yes __no
equal movement when raised __yes __no
Eyelashes
equally distributed __yes __no
Eyelids
presence of discharge __yes __no
discolorations yes __no
involuntary blinks __yes __no
Eyes
transparent bublar conjunctiva __yes __no
sclera appeared white __yes __no
palpebral conjunctiva __shiny __smooth __pink
 lacrimal gland __edema __tearing
PERRLA (pupils equally round and reactive to light) __yes __no
EARS
symmetrical auricles __yes __no __mobile
__firm __tender
Hearing
watch tick test _____________

NOSE AND SINUS

Nose
symmetric __yes __no
uniform in color __yes __no
discharge __yes __no
flaring __yes __no
tenderness __yes __no
Mouth
Teeth Gums
color of gums __________
color of soft and hard palate _____________
position of the uvula ______________
Neck
equal in size __yes __no
lymph nodes __yes __no
visible thyroid gland __yes __no
placement of trachea ________________

THORAX, LUNGS, AND ABDOMEN

Lungs/Chest
symmetric expansion __yes __no
tenderness and masses __yes __no
vertically aligned spine __yes __no
respiratory rate ____ breaths per minute
Heart
presence of hives __yes __no
visible pulsations on pulmonic and aortic areas __yes __no
heart rate____beats per minute
Abdomen
skin _________________________
symmetric contour __yes __no
bowel sounds__________________

EXTREMITIES
Muscles
tremors __yes __no
firm __yes __no
coordinated movements __yes __no
Bones
 deformities __yes __no
tenderness __yes __no
swelling __yes __no

Joints
swelling __yes __no
joints can move smoothly __yes __no

A.) Family
How many members? _______
How many siblings do you have?________
Type of family structure
__ matriarchal __patriarchal __nuclear __extended

Name Birthday Sex Civil Status Position in Occupation

the Family

Do you have any family conflicts?

___ yes ___ no
Do you have any family bonding days?
___ yes ___ no

B.) Socio-economic and Cultural

Occupation
Mother ___________________
Father__________________
Do you think you have enough clothes to wear? __ yes __no
How is your relationship with your family? Are you close with them? __ yes __no
Who takes care of you at home? ____________________________________
How often do you go to church? ________________________________
What is/are your family traditions and practices?
____________________________________________________________________
How is your relationship with your community? _______________________________

C.) Home and Environment

How many rooms are there in your house? __________
Do you all have your own bedroom? __ yes __no
Do you ever see mosquitoes, cockroaches, flies, and rats inside your house?
__ yes __ no
Do you have a refrigerator to store you foods? __ yes __ no
Does your parents cook on:
__ electric stove
__ gas stove (super kalan)
 Where do you get your drinking water? _____________
Is there a toilet inside your house? __yes __no
Where do you throw your trash in?
__open container
__closed container

Type of drainage system _________________________

Kind of neighbourhood (ex. Congested, slum, ect) _______________________
Social and health facilities available? __________________________
Communication and transportation facilities available _______________________
D.) Health Status
Immunizations ____________________________________________
Have you ever had
__chickenpox
__measles __ear infections
__mumps __others (please specify___________________)

Have you ever had serious/chronic illnesses

__ meningitis/encephalitis __ other chronic lung conditions
__ Seizure disorders __ rheumatic fever
__ Asthma __ scarlet fever
__ Pneumonia __ Diabetes
__ Kidney problems __ sickle cell anaemia
__ High blood pressure __ allergies

Family health history _________________________________________

Have you ever had a serious injury (e.g. auto accidents, falls, head injuries, fractures, burns, and
poisonings)? __ yes (if so, specify _________) ___no
Do you have any allergies? __ Yes (specify: __________) __ No
How many times in a year do you get a check-up by your Doctor? ________
Have you ever been hospitalized or received an operation? __Yes (Why?_____) __ No
Do you have a medications or vitamins that you take? __ Yes (specify:_____) __ No
How often do you eat per day? ________
What do you usually eat and how much of it per serving?
_______________________________________________

E.) Health, Values

What time do you sleep? _____
What time do you wake up? ______
Do you take naps? __yes __no if yes, how long? _________________________
How long do you play/exercise outside per day? _____________________________
What do you do when youre mad? How do you handle it?
___________________________________________________________________
Do you use promoting or preventive health services? Please specify
___________________________________________________________________