OUR LADY OF FATIMA UNIVERSITY ANTIPOLO

College of Nursing
Community Diagnosis Health Survey Tool

Head of the Family: _______________________________

Control No. ____________
(Kinikilalang puno ng pamilya)
Complete Address: _________________________________________________________________ No. of familiy members:
__________________________________________________________________________________
(Tirahan) (Bilang ng myembro 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
(Antas ng Edukasyon) (Hanapbuhay)
Relationship *7 yrs. & above *15-64 yrs. old
Name of Household to the Head Highest
Civil Status
Members of the Sex Date of Birth Age Educational
No. (Estado sibil) Religion
(Pangalan ng Family (Kasa- (m-dy-yr) (Edad) Attainment Educational Occupational
(Blg.) *15 yrs. & (Relihiyon)
miyembro ng (Kaugnayan rian) (kapanganakan) (Pinakama- Status Type Place Status
above
pamilya) sa puno ng taas na (Antas ng (Uri) (Lugar) (Kalagayan
pamilya) Antas ng Edukasyon) ng Trabaho)
Edukasyong
natapos)

LEGEND:
M- Male S- Single C- Catholic EG- Elem Grad NF- No Formal
Education
F- Female M- Married P- Protestant EU- Elem Undergrad PS- Presently Studying
W- Widowed SA- 7th Day HG- High school SS- Stopped Studying
Adventist Grad
CL- Common INC- Iglesia ni HU- High school C- College Graduate
law Cristo Grad
Sep- Separated JW- Jehova’s CU- College
Witness Undergrad
V- Vocational
* specify highest educational attainment (PS)

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Community as a Social System B. Political / Leadership Aspect ( ) deep well ( ) artesian well
(Requirement: opening 10% of floor area in sq.m.) ( ) local water system ( ) rain water
A. Economic Aspect a. Recognized leaders in the community ( ) streams, rivers, or spring
(unang taong kinukunsulta at e. Lighting – facilities
a. Combined monthly family income kinikilalang puno ng komunidad)
(Buwanang kita ng pamilya) ( ) electricity ( ) kerosene ( ) candles Level
( ) Barangay officials ( ) Religious leaders ( ) Others, pls. specify: _______________ ( ) Level I
( ) P1,000 and below ( ) P15,001 – P20,000 ( ) Non-gov’t organizations ( ) elders ( ) Level II
( ) P1,001 – P5,000 ( ) P20,001 – P25,000 ( ) Others, pls. specify: ____________________ _____ adequate _____ inadequate ( ) Level III
( ) P5,001 – P10,000 ( ) P25,001 – P30,000
f. Excreta Disposal (Uri ng palikuran)
( ) P10,001 – P15,000 ( ) P30,001 and above
o. Storage of drinking water (imbakan ng
b. Other sources of income (livelihood) b. Community Program ( ) pail system ( ) open pit inuming tubig)
(Ano ang mga alam na programa sa ( ) flush type ( ) closed pit
komunidad?) ( ) bored hole latrine ( ) water-sealed ( ) jar (banga) ( ) plastic/glass container
(Mayroon pa bang ibang
pinagkukunan ng kabuhayan?) ( ) overhung latrine ( ) bottles ( ) drum
* indicate the profit earned then add to ( ) peace and order ( ) fumigation ( ) water tank ( ) water dispenser
the monthly family income ( ) curfew ( ) tapat ko linis ko g. Sanitary condition of toilet facility ______ covered ______ uncovered
( ) sportsfest
( ) Yes ( ) No ( ) Others, pls. specify: ____________________ ( ) good ( ) fair ( ) poor
If yes, what? (kung mayroon, ano?)
( ) sari-sari store ( ) poultry c. Predominant organizations in the h. Ownership of toilet facilities
community (pagmamay-ari ng palikuran)
raising ( ) craft making ( )
livestock raising (Kilalang samahan sa komunidad) p. Method commonly used in sanitizing
( ) Others, pls. specify: ( ) private (sariling gamit) water (Paraang ginagamit upang mapanatiling
_______________ ( ) Barangay Council ( ) shared (may kahati sa gamit) malinis ang inuming tubig)
( ) Sangguniang Kabataan ( ) public (gamit pambayan)
c. Monthly family expenditure (Buwanang ( ) Couples for Christ ( ) boiling (pagpapakulo)
gastusin ng pamilya) ( ) Seniors Citizens Club i. Sewerage system of the family (Uri ng ______ for how long? (gaano
( ) Others, pls. specify: _____________________ kanal ng pamilya) katagal?)
( ) filtration (pagsasala)
( ) P1,000 and below ( ) P15,001 – P20,000
( ) P1,001 – P5,000 ( ) P20,001 – P25,000 d. Traditions celebrated, observed in the ( ) blind drainage ( ) open drainage ( ) ( ) sedimentation (pagpapalatak)
( ) P5,001 – P10,000 ( ) P25,001 – P30,000 community none ( ) Others, pls. specify: _______________
( ) P10,001 – P15,000 ( ) P30,001 and above
( ) Fiesta ( ) Thanksgiving ( ) Holy Week j. Condition (kalagayan ng daloy ng tubig
d. Priority expenditure, rank it 1-7 (1 is the ( ) Others, pls. specify: _____________________ sa kanal)
highest, 7 is the lowest) q. Domestic animals upkeep (dogs & cats only)
C. Environmental Aspect ( ) free flowing ( ) stagnant
_____ food (pagkain) Vaccination
k. Type of garbage disposal used (Uri ng Num
_____ health (kalusugan) a. Land ownership (Pagmamay-ari ng Place kept (Bakuna sa hayop)
pagtatapon ng basura) Kind ber
_____ house rental (upa sa bahay) lupang tinitirahan) (pinaglalag With
(Uri) (Bila Without
_____ education yan) (mayro
( ) animal feed ( ) composting ng) (wala)
(edukasyon) ( ) owned ( ) rented ( ) lease to own on)
_____ electric bill (bayarin sa ( ) rent free ( ) Others, pls. specify: ( ) open dumping ( ) burial pit
kuryente) __________________________________________ ( ) burning ( ) garbage collection( )
_____ (clothing) Others, pls. specify: _______________________
_____ water bill (bayarin sa tubig)
b. House ownership (Pagmamay-ari ng l. Waste garbage segregation
r. Presence of vectors and rodents
e. Resources allotted for health care bahay na tinitirahan) (pagkakaroon ng peste sa bahay)
(Nakalaang pondo para sa kalusugan) _____ Yes _____ No
( ) owned ( ) rented ( ) lease to own ( ) flies (langaw) ( ) termites (anay)
( ) Yes ( ) No ( ) rent free ( ) Others, pls. specify: m. Container used for garbage
( ) rats (daga) ( ) mosquitoes (lamok)
__________________________________________ ( ) roaches (ipis) ( ) Others, pls. specify:
If yes, from where? (kung oo, galing ( ) garbage bag
_______________________________________
( ) waste basket
saan?) c. Type of materials used for house (Uri
ng materyales ng bahay) ( ) sac
( ) Health Insurance ( ) SSS, GSIS ( ) none
s. Presence of breeding sites of vectors
( ) Phil. Health ( ) savings ( ) light ( ) mixed (pagkakaroon ng lugar na pinamamahayan ng
______ covered ______ uncovered
( ) Others, pls. specify: _______________ ( ) strong ( ) makeshift (barong mga peste)
barong)
______ with ______ without
d. Ventilation n. Source of drinking water
If with, specify location
(pinanggagalingan ng inuming tubig)
___________________
( ) well ventilated ( ) fair ( ) poorly
ventilated ( ) commercially prepared water

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 t. Ways of controlling of vectors (paraang
ginagawa upang mapuksa ang mga peste sa
bahay)

( ) fumigation (pagpapausok)
( ) mouse trap
( ) fly traps
( ) insecticides (pamatay insekto i.e. katol)
( ) screens on doors and windows (i.e. kulambo)
( ) Others, pls. specify: ___________

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D. Health Aspect e. First person consulted in times of illness (Unang taong  h and i – If there are children 0-12
kinukunsulta tuwing may magkakasakit) mos. in the family
a. Community health programs (programang pangkalusugan)  j – If there are children 0-83 mos. (0-7
( ) doctor ( ) albularyo yrs) in the family
( ) midwife ( ) relatives  k – If there is a pregnant member of
Aware Utilizes ( ) nurse ( ) faith healer the family
(alam) (nagkukunsulta) ( ) family ( ) BHW
( ) Free consultation ( ) hilot h. Infant feeding program
(libreng konsulta) _____ _____ ( ) Others, pls. specify: _______________
( ) Immunization ( ) breast milk
(libreng bakuna) _____ _____ f. Medications taken during illness (gamot na iniinom) ( ) formula
( ) Family Planning ( ) mixed
(Programa sa pagpa- _____ _____ ( ) prescribed ( ) herbal ( ) over the counter ( ) Others, pls. specify: _______________
plano ng pamilya) ( ) Others, pls. specify: _______________
( ) Pre-natal check-up Formula used:
(Programa para _____ _____ g. Method of family planning (pagpaplano ng pamilya)
sa buntis) *applicable to members of reproductive age _____ condensed milk
( ) Well-baby clinic (15-44 yrs. old) _____ evaporated milk
(konsulta para sa _____ _____ _____ powdered milk
mga sanggol na bata) Non- _____ others, pls. specify: ____________
Name Age Acceptor Method
acceptor
b. Family Health Practices
i. Maternal Care (Pangangalaga sa buntis)
Not
Health Practices Practiced Frequency
practiced
Use of hygienic
products
Sleep 6-8 hrs a day
Brushes teeth
Cuts toenails No.
Expecte Prenata Tetanus Toxoid
Cleans ears of
d date l Immunization
Changes clothes preg
Age of of Check- *indicate how many
Eats balanced diet Nam nanc
Gestation delivery up dosage
Smoking e y
(bilang ng (inaasa
Regular exercise (pan (bila
buwan ng hang
Use of prohibited gala ng W
pagbubunt petsa
drugs n) ng it
is) ng T T
Dental check-up pang Wi h TI TI TI
pangan I I
Drinking alcoholic anga th o 3 4 5
Legend: ganak) 1 2
beverages nak) u
t
Medical check-up r- rhythm
Recreational
Relaxation Activities b- basal body temp

*indicate the name of the member c- cervical mucus method

c. Food usually eaten (madalas na kinakain) g.1. Natural

*majority of the family members
( ) rhythm ( ) cervical mucus method
( ) fish ( ) withdrawal
( ) meat ( ) basal body temperature
( ) vegetable ( ) Others, pls. specify: _______________
( ) mixed
( ) Others, pls. specify: _______________ g.2. Artificial contraceptives

d. Food storage practices (Pangangalaga sa pagkain) ( ) condoms ( ) IUD ( ) pills

( ) Others, pls. specify: ______________
( ) refrigerator ( ) table ( ) basket
( ) Others, pls. specify: _______________
g.3. Permanent
_____ covered _____ uncovered
( ) vasectomy
( ) tubal ligation

 For items h-k: Answer only if applicable

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j. Immunization Status of Target Age Group (0-12 mos.)

DPT OPV Hepatitis B Remarks

fully-
Incomplete Complete
Age in immunized
Name BCG AMV (applicable (applicable
Mos. 1 2 3 1 2 3 1 2 3 (applicable
to 0-12 to 0-9
to 9-12
mos.) mos.)
mos.)

k. Morbidity (w/in 1 whole year) * Jan 1 – Dec 31

Name Age Sex Intervention

(pangalan) (edad) (kasarian) (Medication/Hospitalization)
with without

l. Mortality (w/in 1 whole year) * Jan 1 – Dec 31

Name Age Sex Cause of death

(pangalan) (edad) (kasarian) (dahilan ng pagkamatay)

m. Blood pressure (18 yrs. & above)

Risk Factors
Familial history
Name Age Sex Diet
BP reading of
(pangalan) (edad) (kasarian) (high fat/high Exercise Smoking Alcohol drinking
hypertension
salt)