UNCIANO COLLEGES, INC.

Antipolo City

COLLEGE OF NURSING

COMMUNITY HEALTH SURVEY TOOL

I. Household Members

Surname Given Middle Age Sex Family Relation Birth Civil Highest Occupation Immunization Literacy Remarks
Educationa
Name Initial Position to the Date Status and Status Status
(Ordinal) l
Head Daily/Monthly
Attainment
Salary
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Put * after the surname of deceased individual. Write the cause and place of death under the remarks column.In addition, note down in the same column any health
abnormalities of the above individuals indicating in terms of prenatal,postpartum, mentally retarded, morbid case (specify present illness), malnourished, and overweight. Indicate
the place of birth for neonates. Mark (x) if not immunized, C for complete and (?) if not known. Place O.S. if out of school then write the reson under the column remarks. Used
the term employed, and unemployed for their occupational status. Indicate the literacy status whether literate (can read and write) or illiterate.

II. Length of Residency ___________

III. Religion/Sect [ ] Roman Catholic [ ] Mormon [ ] Seventh Day Adventist [ ] Others (specify)

[ ] Born Again Christian [ ] SAKSI [ ] Islam

[ ] Region VI [ ] Region VIII [ ] Region X [ ] Region XII [ ] CARAGA

[ ] ARMM [ ] Abroad (specify):___________________

Specify the province:___________________

V. Medium of Communication (Sending and Receiving Information) [ ] Cell phone [ ] Radio [ ] Landline [ ] Television

VI. Transportation Facility [ ] Pedicab/Bicycle [ ] Motorbike [ ] Tricycle [ ] Jeep [ ] Bus [ ] Taxi/Fx

VII. Accident Hazards [ ] None [ ] Broken Stairs [ ] Poisons [ ] Pointed/Sharp objects [ ] Fire Hazards [ ] Fall Hazards

[ ] Others (specify):_________________________

VIII. Ethnicity [ ] Bicolano [ ] Ibanag [ ] Ilocano [ ] Ivatan [ ] Kapampangan [ ] Moro

[ ] Pangasinense [ ] Sambal [ ] Tagalog [ ] Visayan [ ] Tribal Group (specify):__________________

IX. Language/Dialect Spoken [ ] Agta [ ] Ayta [ ] Bagobo [ ] Bantuanon [ ] Bikolano [ ] Bolinao [ ] Cebuano

[ ] Chavacano [ ] Davaweno [ ] Dumagat [ ] Filipino [ ] Hiligaynon [ ] Ifugao [ ] Ilocano

[ ] English [ ] Manobo [ ] Masbateno [ ] Pampangan [ ] Pangasinan [ ] Others (specify):_______________

X. What are your health beliefs and practices? 1. ________________________________________________________________________________

2. ________________________________________________________________________________

3. ________________________________________________________________________________

XI. What are your concepts about health and illness? 1. ____________________________________________________________________________

2. ____________________________________________________________________________

3. ____________________________________________________________________________

XII. Income Total/Month (Check the bracket)

[ ] Below Php. 5,000.00

[ ] Php. 10,100 Php. 10,000.00

[ ] Php. 10,100 Php. 15,000.00

[ ] Php. 15,100 Php. 20,000

[ ] Php. 20,100 Php. 30,000.00

[ ] Php. 30,100 Php. 40,000

[ ] Php. 40,100 Php. 50,000

Others (specify):_____________________

XIII. Agency Utilized for Seeking Health Care [ ] Barangay Health Station [ ] Rural Health Unit [ ] Hospital

XIV. Social and Health Facility [ ] Basketball court [ ] Social Hall [ ] Barangay Hall [ ] Health Center [ ] Market [ ] Hospital

XV. Housing

a) Type of House [ ] Strong [ ] Wood [ ] Mixed [ ] Light [ ] Makeshift

b) Ownership [ ] Owned [ ] Rented [ ] Rented Free

c) Ventilation [ ] Satisfactory [ ] Fair and Below Poor

d) Overcrowding [ ] Overcrowded [ ] Not Overcrowded/Living Space Adequate

XVI. Environment

a) Water Supply [ ] Point Source (Level 1) [ ] Communal Faucet System (Level 2) [ ] Waterworks System or Individual House Connection (Level 3)

b) Excreta Disposal [ ] Water-sealed Latrine/Hand-flushed [ ] Septic Tank [ ]Balot System or Wrap and Throw

[ ] Others (specify):___________________

c) Garbage Disposal [ ] Collected [ ] Animal Feeding [ ] Composting [ ] Burial Pit [ ] Recycling

d) Income Status [ ] High Income Group [ ] Moderate Income Group [ ] Low Income Group

XVII. Industry [ ] Mining [ ] Farming [ ] Refining [ ] Construction [ ] Manufacturing [ ] Others (specify):________________________

XVIII. Pollution [ ] None [ ] Air [ ] Water [ ] Land

XIX. Government Programs Being Utilized [ ] Family Health:____________________________________________________________________________________

[ ] Non-Communicable Disease Prevention and Control:___________________________________________________

[ ] Communicable Disease Prevention and Control:_______________________________________________________

[ ] Environmental Health and Sanitation:________________________________________________________________

[ ] Others (specify):_________________________________________________________________________________

The following initials can be used:

Family position: F- father GF- grandfather H- housekeeper

M- mother GM- grandmother

S- son U- uncle

D- daughter A- aunt
Civil Status: M- married S- single

W- widow Sep.- separated

CL- common law

Cause of Death: HD- heart disease VSD- vascular system disease A- accident

MD- malignant neoplasm P- pneumonia TB- tuberculosis

CLRD- chronic lower respiratory disease DM- diabetes mellitus PC- perinatal complication

U- unknown cause Others (specify):_________________

*Based on: MORTALITY: TEN LEADING CAUSES BY SEX

Educational Attainment: CG- college graduate CL- in undergraduate level, indicate what level

HG- highschool graduate HL- highschool undergraduate

EG- elementary graduate EL- elementary level

K- kindergarten P- prep

N- nursery