CENTRAL LUZON DOCTORS’ HOSPITAL EDUCATIONAL INSTITUTION
COMMUNITY SURVEY TOOL
BARANGAY: ___________________________________ DISTRICT : ________________________
ZONE/PUROK/SITIO: ___________________________ MUNICIPALITY: ________________________
PROVINCE : ________________________
I. FAMILY STRUCTURE
A. Type of Family (put a check mark on the space provided)
Nuclear _____ Extended _____ Others _________________
B. Members of the Household
NAME RELATION SEX AGE CITIZENSHIP CIVIL RELIGION EDUCATIONAL IF OSY: OCCUPATION
(Including Head of the Family) TO HEAD STATUS ATTAINMENT REASON
(6-21 yrs./old)
1.
2.
3.
4.
5.
6
7.
8.
9.
10.
11.
12.
13.
14.
15.
C. Female Reproductive Age
Name Age on First Pregnancy Nature of Delivery OB Score
1. ______________________________ _____________ _______________ _______________
2. ______________________________ _____________ _______________ _______________
3. ______________________________ _____________ _______________ _______________
4. ______________________________ _____________ _______________ _______________
5. ______________________________ _____________ _______________ _______________
II. SOCIOECONOMIC AND CULTURE PROFILE
A. Monthly Income of Household ___________________
B. Monthly Expenses _______ __________ _______ _________ _________ _______ __________ _________
(Food) (Electricity) (House) (Clothes) (Water) (Health) (Education) (Leisure)
Total Expenses _______________
C. Religion
_____ Roman Catholic _____ Philippine Independent Church _____ Jehovas’ Witness
_____ Iglesia ni Kristo _____ Born Again Christian Others (Pls. specify) ________________________
D. Health Practices
_____ Herbolarios _____ Doctor _____ BHC/CHC Others ______________________
E. Ethnicity
_____ Ilocano _____ Pampango _____ Tagalog Others ______________________
F. Existence of Backyard Livelihood
_____ Piggery _____ Chicken Raising _____ Vegetable Gardening Others ______________________
III. HOME AND ENVIRONMENT
A. Home and Lot Ownership H. Food Storage
House Lot _____ Refrigerator Others ______________________
_____ Owned _____ Owned
_____ Rented _____ Rented I. Storage of Drinking Water
_____ With Cover _____ Without Cover
B. Residency (Length of Stay)
_____ Number of years
J. Garbage Disposal System
a)_____ Compost Pit _____ Burning ______Others
C. Types of Building
_____ Concrete _____ Wood _______ Mixed K). Type of Toilet
_____ Light Concrete Wood _____ Makeshift/Nipa Hut _____ Pit Latrine _____ Pail System
D. Ventilation
_____ Adequate _____ Inadequate _____ Septic Tank/Flush _____ None
E. Source of Lighting L. Toilet Hygiene Status
_____ Electricity _____ Gas Lamp _____ Very Clean _____ Dirty
_____ Candle Others __________________ _____ Clean
F. Adequacy of Lighting M. General Home Sanitary Condition
_____ Adequate _____ Inadequate _____ Very Clean _____ Clean _____ Dirty
G. Means of Cooking N. General Backyard Sanitation
_____ Gas Stove ________ Wood/Charcoal _____ Very Clean _____ Clean _____ Dirty
_____ Kerosene _________ Others O. Drainage System
______Open _____None
______Blind
IV. RESPONSIBLE PARENTHOOD MEASURES
A. Family Planning (For Childbearing Female Members Only) C. Morbidity
_____ Natural Illness Frequency (Monthly Basis)
_____ Artificial 1. __________________ ____________
_____ IUD _____ Not practicing Family Planning 2. __________________ ____________
_____ Rhythm _____ Ligation 3. __________________ ____________
_____ Pills _____ Condom 4. __________________ ____________
B. Source of Family Planning Information D. Mortality Distribution
_____ Health Center _____ Hospital Name of Dead Family Member Cause of Death / Age
_____ Mass Media _____ Family Doctor 1. ________________________ ____________
2. ________________________ ____________
3. ________________________ ____________
V. HEALTH CARE STRATEGIES
A. Birth Attendant
_____ Hilot _____ Midwife _____ Doctor Others ____________________
B. Place of Delivery
_____ Private Hospital _____ Provincial/District Hospital _____ Lying-in-Clinic _____ House _____ BHC
C. Infant Feeding
_____ Breast Feeding _____ Bottle Feeding _____ Mixed Feeding Others (pls. specify) _______________________
D. Children Health Profile (under 7 years old)
Immunization
NAME SEX AGE HEIGHT WEIGHT DPT OPV HEP BCG Measles
1 2 3 1 2 3 1 2 3 1 2 3 1 2 3
1.
2.
3.
4.
5.
6.
7.
E. Food Source
_____ Market _____ Sari-Sari _____ Ambulant Store _____ Own Produce Others ___________________
F. Water Source
_____ Deep well _____ Distribution _____ Communal _____ Jet Matic Others ___________________
G. General Health Status of Family Members
_____ Nourished _____ Undernourished _____ Overnourished
VI. KNOWLEDGE OF THE CONCEPT OF HEALTH CARE
A. Maternal and Child Care Agree Disagree No Knowledge
(3) (2) (1)
1. Headache, dizziness, and edema of the face, hands and legs are common signs/discomforts of pregnancy. _____ _____ _____
2. Umbilical cord of the newborn baby that remains fresh may only be cleaned by wiping. _____ _____ _____
3. Breastfed infants are healthier than bottle fed ones. _____ _____ _____
4. Thick clothing should be removed when babies have fever to lower body temperature. _____ _____ _____
5. Family planning is good to ensure good maternal and child health. _____ _____ _____
6. Pre-natal check-ups are important to prevent complications. _____ _____ _____
7. Vitamins, milk and good diet help the pregnant mother maintain good health. _____ _____ _____
B. Communicable Disease Agree Disagree No Knowledge
(3) (2) (1)
1. Communicable diseases such as measles, TB, poliomyelitis, diphtheria and tetanus can be prevented. _____ _____ _____
2. Blood striated sputum from coughing is a symptom of diarrhea. _____ _____ _____
3. Quarantine person with communicable disease. _____ _____ _____
4. Drink lots of water, juice and vitamins when you have coughs and colds. _____ _____ _____
5. Separate utensils of sick member as they may spread infection to others members of the family. _____ _____ _____
C. First-Aid Practices
1. Small cuts and contusions may be cleaned using soap and tap water. _____ _____ _____
2. Open and expose the wound caused by deep penetration of sharp objects to prevent growth of bacteria. _____ _____ _____
3. Have drowned patients laid on surface and squeeze stomach tightly to expel ingested water. _____ _____ _____
4. Fracture, sprains and dislocations must be immobilized either through bandaging or splinting. _____ _____ _____
5. Dogbites can be managed by washing with soap & water and immediately brought to the nearby center/hospital. _____ _____ _____
D. General Health Care
1. Foods rich in protein such as meat, fish and egg are needed for good health. _____ _____ _____
2. Oresol is given to babies who have diarrhea and can be substituted with water and salt. _____ _____ _____
3. Herbal medicine is safe and no side effects even when taken in large amounts. _____ _____ _____
4. Females should not take a bath during their menstrual period. _____ _____ _____
5. Eating eggs and wearing black clothing can hasten lesions to come out in cases of measles. _____ _____ _____
VII. RELEVANT ISSUES AND CONCERNS
A. Family Problems (Please Check the Problem) B. Community Problems (Please Check the Problem)
_____ 1. Inadequate resources to send children to school. _____ 1. School is far from home.
_____ 2. Inadequate food due to unemployment. _____ 2. BHC does not have adequate health services.
_____ 3. Scarce budget for medicines and vitamins. _____ 3. Harassment from lawless residents.
_____ 4. Large family size. _____ 4. No opportunity for employment.
_____ 5. Ignorance of family planning measures. _____ 5. Inadequate government support during natural calamities.
_____ 6. Others ________________________________ _____ 6. Others ________________________________________
B. Suggestions to Solve Problems
1. ______________________________________________ 1. ___________________________________________________
2. ______________________________________________ 2. ___________________________________________________
3. ______________________________________________ 3. ___________________________________________________
4. ______________________________________________ 4. ___________________________________________________
5. ______________________________________________ 5. ___________________________________________________
