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Community Health Assessment Form

Respondent: _____________________________________________
Age: _____________
Sex: _____________
Relation to Head: ________________________ (If not the head of the
family)
I.

Family Data
A. Head of the Family _____________________________
Age: ___________
B. Name of Spouse _______________________________
Age: ___________
C. Address ________________________________________
D. Educational Attainment _________________________
Husband: _________________________________
Wife: _____________________________________
E. Length of Residency _____________________________
F. Family Structure
) Nuclear
(
( ) Extended
) Single-Parent
(
G. Religion ________________________________________
H. Number of Children______________________________
I. Members of the Household

Name

Age

Sex

Education

Occupation

Facilitative Interaction among Members


A. Is there frequent communication among all members?
( ) Most of the time
( ) Seldom

( ) Frequently
( ) Never

B. Are relationships supportive?


( ) Most of the time
( ) Seldom

( ) Frequently
( ) Never

C. Are love and caring shown among members?

( ) (Most of the time


( ) (Seldom

( ) (Frequently
( ) (Never

D. Do members work collaboratively?


( ) (Most of the time
( ) (Seldom

( ) (Frequently
( ) (Never

Enhancement of Individual Development


A. Does family respond appropriately to members
developmental needs?
( ) (Most of the time
( ) (Seldom

( ) (Frequently
( ) (Never

B. Does it tolerate disagreement?


( ) Most of the time

( ) Frequently

( ) Seldom
( ) Never
C. Does it accept member as they are?
( ) Most of the time
( ) Seldom

( ) Frequently
( ) Never

D. Does it promote member autonomy?


( ) (Most of the time
( ) (Seldom

( ) (Frequently
( ) (Never

Healthy Environment and Lifestyle


A. Is family lifestyle health promoting?
( ) (Most of the time
( ) (Seldom

( ) (Frequently
( ) (Never

B. Are living conditions safe and hygienic?


( ) (Most of the time
( ) (Seldom

( ) (Frequently
( ) (Never

C. Is emotional climate conducive to good health?

( ) (Most of the time


( ) (Seldom

( ) (Frequently
( ) (Never

D. Do members practice good health measure?


( ) (Most of the time
( ) (Seldom
II.

( ) (Frequently
( ) (Never

Socioeconomic Data
A. Source of Income
Occupation: _______________________________
Husband: __________________________________
Wife: _______________________________________
Employed ( )
Unemployed ( )

( ) Self Employed
Monthly Income:
( ) Below P2,000
( ) P5,000 - P8,000

( ) P2,000 - P5,000
( ) more than P8,000

Adequacy to Meet Basic Necessities:


( ) Adequate
( ) Inadequate
B. Family Expenditures
1. Food ( daily)
( ) Below P50
( ) More than P70

( ) P50 P75

Clothing:
2.
Number of times buying
( ) Once a year
( ) Twice a year
( ) Thrice a year
( ) Monthly
Housing
3.
( ) Water
( ) Telephone

( ) Electricity
( ) Internet Access

Schooling
( ) Public
III.

( ) Private

Housing and Environmental Condition


A. House:
Ownership:
( ) Owned
( ) Rented


Type:
Adequacy of Living Space
( ) Adequate
( ) Inadequate
Ventilation:
( ) Good

( ) Poor

Lighting:
( ) Candles
( ) Fluorescent

( ) Lamp
( )Others, pls. specify_______________

Sleeping Arrangement
( ) Bedroom
( ) Outside the house

( ) Sala
( ) Others, pls. specify_______________

Adequacy of the furniture/ appliances


( ) Adequate
( ) Inadequate
Surroundings:
( ) Clean
( ) Dirty
( ) Trees and plants
( ) Presence of plastics
around
( ) Presence of broken
( ) Presence of dried
glasses
leaves
( ) Presence of fecal
( )Others, pls. specify_______________
B. Source of Water Supply
( ) Artesian Well
( ) Deep Well
( ) River
( ) NAWASA
( ) Others, pls. specify_______________

C. Storage of Drinking Water


( ) Refrigerated
( ) Uncovered

( ) Covered
( ) Others, pls. specify_______________

Containers Used:
( ) Plastics
( ) Bottles

( ) Clay Jars
( ) Others, pls. specify_______________

D. Toilet Facilities
Sanitary:
( ) Flush
( ) Shared
( ) Public

( ) Pit Privy
( ) Owned
( ) Others, pls. specify_______________

Unsanitary
( ) Balot System

( ) Others, pls. specify_______________

E. Garbage Disposal
( ) Collection
( ) Burying
( ) Others, pls. specify_______________

( ) Burning
( ) Open Dumping

F. Food Storage
( ) Refrigerated
( ) Uncovered

( ) Covered
( ) Others, pls. specify_______________

Containers Used:
( ) Plastics
( ) Metal Pots

( ) Clay Pots
( ) Others, pls. specify_______________

G. Presence of Animals
( ) Dogs
( ) Cats
( ) Cows

( ) Pigs
( ) Chickens
( ) Others, pls. specify_______________

H. Presence of insects and rodents


( ) Present
( ) None
Types:
( ) Mosquitos
( ) Flies
( ) Bees
( ) Cockroaches
( ) Ants
( ) Spiders
( ) Others, pls. specify________________
I. Presence of breeding sites for insects and rodents
( ) Present
( ) None
Types:
( ) Domestic Containers
( ) Animal Manures
( ) Roof Gutter
( ) Garbage dumps

( ) Flower Pots
( ) Discarded Tires
( ) Canals
( ) Others, pls. specify______________

J. Presence of Accident Hazards


( ) Present

( ) None

Types:
( ) Broken Stairs
( ) Plastics
( ) Improperly Kept Medicines

( ) Pointed/ Sharp
Materials
( ) Banana Peelings
( ) Chemicals

( ) Improperly Kept Matches ( ) Others, pls. specify___________


K. Backyard Gathering
( ) Vegetables
( ) Herbal
( ) Fruit- bearing
( ) Floral Plants
( ) Others, pls. specify_________________
L. Road
( ) Cemented

( ) Uncemented

IV. Health/ Health Resources


A. Heredofamilial Disease
( ) Hypertension
( )Cancer
( ) Diabetes
( ) Asthma
( ) Others, pls. specify_____________________
B. Health and other Facilities
( ) Health Center
( )Barangay Hall
( ) School
( ) Church
( ) Park
( ) Market
( ) Others, pls. specify___________________
C. Indigenous Health Workers
( ) Trained Hilot
( )Albularyo
( ) Untrained Hilot
( ) BHW
( ) Others, pls. specify___________________
D. Sources of Health Funds
( ) Government
( ) NGOs/ POs

( )Private
( ) Others, pls. specify_________________

E. Personal Habits/ Practices


( ) Exercises Regularly
( ) Balance Diet
( ) Frequent drinking of
( ) Excessive Smoking
Alcohol
( ) Walking Barefooted
( ) Eating Raw Meat/ Fish
( ) Poor Personal Hygiene
( ) Self- Medication
( ) Use of Dangerous Drugs/
( ) Engaging in Dangerous
Narcotics
Sports
( ) Others, pls. specify_____________________
V.

Nutrition
A. Food Preferences
( )(Fish
( )(Fruits/ Vegetables

( ) Meat
( ) Mixed

B. Common Fare
( )(Rice and Egg
( )(Rice and Noodles

( ) Rice and Sardines


( ) Others, pls. specify_______________

C. Presence of Nutritional Disorder


1. Goiter
( ) Enlargement of the neck
( ) Hoarseness
( ) Dysphagia
( ) Others, pls. specify____________________
2. Anemia
( ) Pallor
( ) Body Weakness
( ) Easy Fatigability
( ) Others, pls. specify____________________

3. Vitamin A Deficiency
( ) Night Blindness ( ) Pilak sa Mata
( ) Others, pls. specify___________________
4. Obesity
BMI: ___________________________
Waist Circumference: __________
WHR: __________________________
VI.

Knowledge, Attitude and Practice


A. Do you utilize the health center?
( ) Yes

( ) (No

B. Reason:
(
(
(
(

) Illness
( ) (Prenatal
) Family Planning
( ) (Postnatal
) Dental
( ) (Nutrition
) Others, pls. specify___________
______

C. First person consulted in times of illness?


( ) M. D .
( ) Nurse
( ) Midwife
( ) BHW
( ) Hilot
( ) Albularyo
( ) Others, pls. specify________________
D. Usual Illness in the Family
( ) Cough
( ) Fever

( ) (Colds
( ) (Others, pls. specify___________

What do you do for this condition?


( ) Self- medication

( ) Consultation

( ) Hospital
(
( ) Others,
(
pls. specify______________

( ) (Health Station

E. Other Diseases
( ) (Tuberculosis
) L( ) (Leprosy
( ) (Skin Diseases
( ) (Hepatitis
( ) (Others, pls. specify_______________
F. Do you submit your children (0-12 months) for
immunization?
Name of
Child

Birthday

BCG Hep
B

DPT MMR OPV Hib AMV

G.
Do you practice Family Planning Methods?
( ) Yes
( ) No
If No, Why? __________________________________________________
H. Method of Infant Feeding?
( ) (Breast
( ) (Bottle
( ) (Mixed
( ) (Others, pls. specify_______________
H. Subjects you want to learn in health education?
( ) Drug Abuse
( ) Nutrition

( ) Family Planning
( ) First Aid Measures
( ) Others, pls. specify_______________

( ) (Environmental
Sanitation
( ) (Herbal Plants

Interviewed By: _______________________


Date: _________________ Time: _________________