BULACAN STATE UNIVERSITY

College oI Nursing

SURVEY TALLY SHEET

Student Name: BALGOS, ANA MARGARITA M.
Year and Section: 2-C

I. EMOGRAPHIC VARIABLE
O SEX
M IIIII-III
F IIII

4 CIVIL STATUS
C IIIII
S
M IIII
MS II
W
Wr I

4 RELIGION
RC IIIII-IIIII-III
P
INC
BAC
1W
M
(OTHER, SPECIFY)
4 EUCATION
P
EL II
EG
HL III
HG I
V
SC
CL I
CG IIIII
PG
NONE

4 PLACE OF ORIGIN
NCR
CL IIIII-IIIII-III
NL
SL
V
M

4 TYPE OF WORK
E II
RF
RP
C
CW
CE
SE III
E
UE IIIII-III

4 PLACE OF WORK
LOCATION :
I
IM/C II
O II
OFW I
PLACE :
OF II
FC
FL

A. Type Of Family
NUCLEAR I
EXTENE I
SINGLE-
PARENT
I
YA
HOMOSEXUAL
COHABITING

MATRIARCHAL
PATRIARCHAL I
EGALITARIAN II

MATRICENTRIC
PATRICENTRIC
PATRILOCAL I
MATRILOCAL I
NEOLOCAL I



A. ialect Frequently Used
FILIPINO/TAGALOG IIIII-IIIII-III
KAPAMPANGAN
BISAYA
ILOCANO
ENGLISH
(OTHER, SPECIFY)



I. SOCIO-ECONOMIC, CULTURAL and ENVIRONMENTAL
1. Social-indicators (for observation and key informant interview)
2. Economic Indicator
Monthly Income
Less than-5,000 I
5,001-10,000 I
10,001-15,000
15,001-20,000
20,001-25,000
25,001-30,000
30,001 - 35,000
35,001-40,000
40,001-45,000
45,001-50,000
50,001 and above I

Financial Source of Family Expenditures
Employment III
Business
Pension
Help from relative/friend
(OTHER, SPECIFY)

Monthly Family Expenditures
Less than-5,000 I
5,001-10,000 I
10,001-15,000
15,001-20,000
20,001-25,000
25,001-30,000
30,001 - 35,000
35,001-40,000
40,001-45,000
45,001-50,000
50,001 and above I

Priorities and Expenditures
what is the most or the #1 prioritize among the choices?
Food III
Education
Health
Recreation
Education
Savings
Utilities

The #2 prioritization of the family?
Food
Education II
Health I
Recreation
Education
Savings
Utilities

And the last.
Food
Education
Health I
Recreation
Education
Savings
Utilities I
CLOTHING-I
ecision maker when it comes to Financial Aspects
Father I
Mother
Both II
Others

Adequacy of Family Income
Adequate I
Inadequate II

3. CULTURAL INICATOR
Cultural Orientation regarding illness
Believe that illness is caused by physiologic
factor
I
Believe that illness is caused by supernatural
phenomenon

Believe that illness is a punishment from God
Believe that illness is caused by other people
Believe that illness is caused by change in
weather
II
(OTHER, SPECIFY)



Cultural belief
Health can be restored by God / other
spiritual faith

Health can be restored by faith healers
Health can be restored by supernatural
power

Health can be restored by health personnel III

Cultural Practices
ALWAYS practices local cultural practices
about health matters
I
SOMETIMES practices local cultural
practices about health matters
II
oes NOT practice any local cultural
practices about health matters


Community Involvement
ACTIVELY joins fiesta, rel.
procession, local cultural
practices
III
oes NOT actively join

4. ENVIRONMENT INICATOR
HOME
A. Ownership :
Owned III
Rented
Rent-free
Least to own

B. Construction Material used :
Light II
Mixed
Strong

C. Number of rooms for sleeping :
0
1 II
2
3 I
4
5

. Adequacy of Space :
Adequate III
Inadequate

E. Lighting Facilities :
Electricity III
Kerosene
(OTHER, SPECIFY)

F. Adequacy of Lighting :
Adequate III
Inadequate

G. Ventilation :
Adequate II
Inadequate I

H. General Sanitary Condition
Very good I
Good I
Poor I



RINKING WATER SUPPLY
A. Ownership :
Private / owned household use
Public III

B. SOURCE :
eep well
Local water
district
II
Commercial I

C. Potability :
YES III
NO

. STORAGE :
None (direct from faucet or pipe)
Large covered container with
Faucet
III
Large uncovered container
without faucet

(OTHER, SPECIFY)

FOO STORAGE/COOKING FACILITIES
A. STORAGE :
Refrigerator
Cabinet
Basket
Table II


Covered II
Uncovered
B. COOKING FACILITY :
Electric stove
Gas stove II
Firewood/charcoal I

C. SANITARY CONITION
Very good I
Good I
Poor I

WASTE ISPOSAL :
A. REFUSE AN GARBAGE :
1. STORAGE :
Container
Plastic Bag III
None

Covered
Uncovered III


2. WASTE SEGREGATION :
Practiced I
Not
practiced


2.1If practiced, method of disposal :
Hog-feeding
Open dumping
Burial in pit
Collected III
Composting


2.2Reason for practicing :
Environmental Friendly
Barangay ordinance which
is strictly monitored
III
Use for business
(OTHER, SPECIFY)

2.3If not practiced, method of disposal
Hog feeding
Garbage collection
Open dumping
Composting
Burial in pit
Open burning
(OTHER, SPECIFY)

2.4Reason for not practicing :
Not aware of effects
Long time practice of family
No time to do it
Not a barangay ordinance/not strictly
monitored


B. TOILET FACILITIES :
1. Ownership :
Owned I
Shared/public II
None





2. Type :
~ballot system
Overhang latrine
Bored-hole latrine
Open pit privy
Antipolo type
Closed pit privy
Water sealed III
(OTHER, SPECIFY)

3. Location for source of water:
Less than 20 ft
20 t beyond III

4. Sanitary condition :
Very good I
Good
Poor II

C. RAINAGE SYSTEM
Open drainage
Blind drainage III
None

CONITION:
Flowing III
Stagnant






PRESENCE OF ANIMALS THAT ARE RABBIES CARRIER
A. ANIMALS RAISE
EXAMPLE :
4 KIN
OG II
CAT I

4 NUMBER
1
2
3
4 and above I

4 WHERE KEPT?
Inside the
yard
I
Free/outside I

4 VACCINATION :
With I
Without I

B. PRACTICES/MEASURES ONE TO CONTROL INSECTS/VECTORS OF ISEASES
Fumigation
Insecticides
Setting traps II
Cleaning the
yard
I
None

C. PRESENCE OF BREEING SITE
With I
None II

HEALTH AN ILLNESS PATERN
I. LIFESTYLE PRACTICES (ACCORING TO FAMILY)
A. HYGIENE
1. Taking bath daily
Practiced II
Not
practiced
I

2. Brushing the teeth
Practiced II
Not
practiced
I

3. Handwashing before and after eating
Practiced III
Not
practiced


4. Nail cutting
Practiced III
Not
practiced


5. Use of hygienic product
Practiced III
Not
practiced


6. Ear cleaning
Practiced II
Not
practiced
I

7. Regular change of clothes
Practiced II
Not
practiced
I



B. REST AN SLEEP
1. Sleeps at least 8 hours a day
Practiced I
Not
practiced
II

2. Takes nap / rest period within the day
Practiced I
Not
practiced
II

C. EXERCISE
1. Perform regular exercise everyday
Practiced I
Not
practiced
II

2. Performs recreational activities
Practiced III
Not
practiced


. HEALTH PROMOTION ACTIVITIES
1. Has a regular medical check-up
Practiced I
Not
practiced
II

2. Has a regular dental check-up
Practiced
Not
practiced
III

E. USE OF SAFETY EQUIPMENTS
Use safety devices when necessary (e.g. helmet, safety belts
Practiced III
Not
practiced



F. IS THERE A MEMBER OF THE FAMILY WHO IS A CIGARETTE SMOKER?
YES II
NO

If yes, indicate the number of the member who is a cigarette smoker per family.
# - 2

G. USE OF PROHIBITE / ANGEROUS RUGS
YES
NO III

If yes, indicate the number of the member who engaged in using prohibited or dangerous drugs.
# - 0

H. RINKS ALCOHOLIC BEVERAGES
YES
NO III

If yes, indicate the number of the member who is alcohol drinker per family.
# -0

II. NUTRITIONAL STATUS
A. ANTHROPOMETRIC ATA
Based on the BMI of the client or member of the family.
Underweight
Normal
Obese
Extremely obese





B. IETARY HISTORY
THE 24 HOUR RECALL.
Is it?
BALANCE II
IMBALANCE I

FOOS USUALLY/MOST TAKEN
1. First choice
Meat only
Fish only III
Vegetable only
Mixed
(other, specify)

2. Number of servings
1 II
2-3 I
4 and above

3. Second choice
Meat only I
Fish only
Vegetable only II
Mixed
(other, specify)

4. Number of servings
1 II
2-3 I
4 and above



5. Reason for choices
Think its healthy I
Personal beliefs/ practice
Own preferences II
Health condition
Affordable

6. Reason for not choosing other options
Not healthy
Personal beliefs/practices
Own preferences III
Health condition
Not affordable

7. From the above response, how frequent is the intake?
Everyday III
Every 3-day
Once a week
(other, specify)

8. How food is prepared for meal time?
Prepared at home III
Bought outside

9. How often?
Everyday II
Every 3-day I
Once a week
(other, specify)




10.If bought outside, it is from?
Restaurant/fast food I
Carinderia
Food cart

11.Reason from the above choices
Convenience
Cheaper
Healthy
Variety of choices I
(other, specify)

12.Takes/ eat canned/preserved food
Everyday II
Every other day
Every week
Sometimes I
Never

13.Takes/eat fried food
Everyday II
Every other day I
Every week
Sometimes
Never

14.rinks carbonated beverages
Occasionally I
Weekly
Everyday




C. BELIEFS AN PRACTICES (per family)
1. Person/nel mostly consulted in times of sickness/illness
octor I
Nurse
Midwife I
Hilot
Albularyo I
Albularyo
Elderly

2. Measures taken in times of sickness/illness
Consult a private health worker I
Consult a rural health team I
See a known community healer
Self-medicate I
None

3. Medication/treatment taken in times of sickness/illness
Prescribed by doctor I
Over the counter/self medication II
Herbals
(other, specify)

4. b. immunization record (0-12 months).
Number of child (0-12 months) per family.
# -

COMPLETE immunization -
INCOMPLTE immunization -

c. FAMILY PLANNING
Acceptor II

Reason:
Good health for the family II
Religious belief
Personal belief
Influence by others
(OTHERS, SPECIFY)

Method:
Natural
Artificial I
Permanent I

Non-acceptor

Reason:
Bad for the health of the family
Religious belief
Personal belief
Influence by others
(OTHERS, SPECIFY)









HEALTH INICATORS
A. MORTALITY -

B. MORBIITY -
HISTORY/PRESENCE of Non-communicable isease in the family
HEART ISEASE
HPN
M
CANCER
KINEY ISEASE
(other, specify)






HISTORY/PRESENCE of Communicable disease in the family
Chicken pox
Measles
engue
Tb
(other, specify) COLS-I