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    SURVEY FORM Back To Back PDF

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    Dan Christian Blance
    This document is a community health survey from the University of Northern Philippines that aims to collect information on the health and living conditions of families in a particular barangay. The survey collects data on family structure, environmental conditions, health beliefs and practices, health history, and perceived community health needs. It seeks to identify any health problems in the community and get recommendations for solutions. The survey will be used to assess the barangay's health status and plan appropriate health interventions.

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    SURVEY FORM Back To Back PDF

    Uploaded by

    Dan Christian Blance
    34 views2 pages
    This document is a community health survey from the University of Northern Philippines that aims to collect information on the health and living conditions of families in a particular barangay. The survey collects data on family structure, environmental conditions, health beliefs and practices, health history, and perceived community health needs. It seeks to identify any health problems in the community and get recommendations for solutions. The survey will be used to assess the barangay's health status and plan appropriate health interventions.

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    SURVEY-FORM-back-to-back.pdf

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    This document is a community health survey from the University of Northern Philippines that aims to collect information on the health and living conditions of families in a particular barangay. The survey collects data on family structure, environmental conditions, health beliefs and practices, health history, and perceived community health needs. It seeks to identify any health problems in the community and get recommendations for solutions. The survey will be used to assess the barangay's health status and plan appropriate health interventions.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    34 views2 pages

    SURVEY FORM Back To Back PDF

    Uploaded by

    Dan Christian Blance
    This document is a community health survey from the University of Northern Philippines that aims to collect information on the health and living conditions of families in a particular barangay. The survey collects data on family structure, environmental conditions, health beliefs and practices, health history, and perceived community health needs. It seeks to identify any health problems in the community and get recommendations for solutions. The survey will be used to assess the barangay's health status and plan appropriate health interventions.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Republic of the Philippines

    UNIVERSITY OF NORTHERN PHILIPPINES


    Tamag, Vigan City
    2700 Ilocos Sur
    COLLEGE OF HEALTH SCIENCES
    Website: www.unp.edu.ph email: [email protected]
    Tel No.: +639177708873

    COMMUNITY HEALTH SURVEY


    Barangay/Municipality: ___________________________________

    Head of the Family: ____________________________________________________________________________

    A. Structure of the Family


    Relationship to Age/ Civil Highest Educational Blood
    Name of Family Member Occupation Remarks
    the Head Sex Status Attainment Type

    B. Environmental Conditions
    1. Toilet Type:  Flush Toilet  Pit Privy  Water sealed  None/Others:_________________
    2. Drainage Type:  Open Blind
    3. Garbage Collection & Disposal :  Composting  Open Dumping  Burning  Others:___________________
    4. Source or Drinking Water:  NAWASA Water Pump  Deep Well
     Unprotected Spring  Others: _____________________
    5. Food Storage:  Cabinet  Refrigerator  Covered with Plate  basket  Others: ___________
    C. Beliefs and Practices
    What are your Beliefs and Practices on the following?
    A. Health Promotion Practices: _____________________________________________________________________

    B. Pregnancy and Child Birth:______________________________________________________________________

    C. Child Feeding: _______________________________________________________________________________

    D. Food Preparation: ____________________________________________________________________________

    E. Food Preference: _____________________________________________________________________________

    F. Medicine Preferences if illness has occurred: ________________________________________________________

    G. Treatment Preferences if illness has occurred: _______________________________________________________

    D. Health History
    Consulted
    Name Illness Medication Used the Doctor? Others:
    (Y/N)
    Republic of the Philippines
    UNIVERSITY OF NORTHERN PHILIPPINES
    Tamag, Vigan City
    2700 Ilocos Sur
    E. Community Health Needs and Problems
    1. How would you rate our community as a “ Healthy Community?”
     Very Unhealthy  Unhealthy  Somewhat Healthy  healthy  Very Healthy
    2. How would you rate your own personal health?
     Very Unhealthy  Unhealthy  Somewhat Healthy  healthy  Very Healthy
    3. How would you rate your Family’s health Status in general?
     Very Unhealthy  Unhealthy  Somewhat Healthy  healthy  Very Healthy
    Aside from illness/diseases acquired, is there any other health problems occurred in our community that needs attention?
    1. ___________________________________________________________________________________________
    2. ___________________________________________________________________________________________
    3. ___________________________________________________________________________________________
    4. ___________________________________________________________________________________________
    5. ___________________________________________________________________________________________

    Do you have any recommended solutions from the above mentioned Health Problems?
    1. ___________________________________________________________________________________________

    2. ___________________________________________________________________________________________

    3. ___________________________________________________________________________________________

    4. ___________________________________________________________________________________________

    5. ___________________________________________________________________________________________

    Others:

    _________________________________________________________________________________________________________

    _________________________________________________________________________________________________________

    _________________________________________________________________________________________________________

    _________________________________________________________________________________________________________

    _________________________________________________________________________________________________________

    _________________________________________________________________________________________________________

    _________________________________________________________________________________________________________

    _________________________________________________________________________________________________________

    ______________________________________________________________________________

    _________________________________ _________________ _______________


    Signature of Interviewee Date Time

    ____________________________________ _________________________________
    Signature Over Printed Name of Interviewer Clinical Instructor

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