APPENDIX C
SURVEY QUESTIONNAORE
For Boarders only
ADVENTIST UNIVERSITY OF THE PHILIPPINES
COLLEGE OF HEALTH
COMMUNITY ASSESSMENT FORM
Interviewer:____________________ Interviewee:_______________________ Date: _________
City Municipality:______________ Zone/Purok:________________ Barangay:_____________
House No./Street/Census No.:_____________________________________________________
NO. NAME BIRTHDAY AGE SEX CIVIL STATUS
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12
13.
14.
15.
LIFESTYLE:
Number of Smokers
Smoking: _______________________________ Not Smoking:_____________________
CIGARETTE CONSUMPTION
NO DURATION CONSUMPTION
AGE
. Week Month Year Sticks Packs
84
Number of Alcohol Drinkers
Drinking:________________________________ Not Drinking:_____________________
ALCOHOL BEVERAGE
FREQUENCY CONSUMPTION DURATION
NO. AGE # of # of
Daily Weekly Occasionally Week Month Year
Glasses Bottles
85
ADVENTIST UNIVERSITY OF THE PHILIPPINES
COLLEGE OF HEALTH
COMMUNITY ASSESSMENT FORM
Interviewer:____________________ Interviewee:_______________________ Date: _________
City Municipality:______________ Zone/Purok:________________ Barangay:_____________
House No./Street/Census No.:_____________________________________________________
POPULATION PROFILE
Birth Civil Educational G/UG Ethnic
No. Name Age Sex Occupation Religion
day Status attainment Course Origin
Family Structure Residence
[ ] Nuclear [ ] Permanent
[ ] Extended [ ] Temporary
[ ] Others
Last School Year Attendance (2012-13)
(6 21 years old)
Elementary Secondary Vocational College
No Not Not Not Not
Schoo- Schoo- Schoo- Schoo-
. ling
Schoo-
ling
Schoo-
ling
Schoo-
ling
Schoo-
ling ling ling ling
86
Sources of Income of the Head of the Family Monthly Income
[ ] Salary
[ ] Sales Head of the Family:
[ ] Fees ____________________
[ ] Rentals
[ ] Pension Gross Family Income:
[ ] Relatives ____________________
[ ] Commission
[ ] No Income
Availability of Transportation Facility Availability of Communication
[ ] Public ____________________________ [ ] Landline [ ] Cell Phone
[ ] Private____________________________ [ ] Radio [ ] Mail
ENVIRONMENT PROFILE
House Ownership House Structure Lot Ownership
[ ] Owned [ ] Concrete [ ] Owned
[ ] Rented [ ] Mixed [ ] Rented
[ ] Rent Free [ ] Makeshift [ ] Rent Free
[ ] Wooden
Type of Housing Flooring No. of Rooms Ventilation
[ ] Single Detached [ ] Cemented [ ] 1 Bedroom [ ] 1 Window
[ ] Single Attached [ ] Wood/Bamboo [ ] 2 or more, specify_____ [ ] 2 or more windows
[ ] 2nd storey attached [ ] Ground [ ] All Purpose specify_______
[ ] 2nd storey detached [ ] Mixed [ ] Door only
[ ] 1st F attached
[ ] 1st F detached
[ ] 2nd F attached
[ ] 2nd F detached
[ ] 3rd F attached
[ ] 3rd F detached
[ ] 3rd storey attached
[ ] 3rd storey detached
Source or Lighting Used
[ ] Electric
[ ] Kerosene
[ ] Candle
[ ] Others, specify________
Water Source Water Usage and Source Level 1 Level 2 Level 3
[ ] Level 1 Drinking [ ] [ ] [ ]
[ ] Level 2 Cooking [ ] [ ] [ ]
[ ] Level 3 General Household [ ] [ ] [ ]
Water Storage for Drinking
[ ] Jug [ ] Not Storing [ ] With Cover
[ ] Bottles [ ] others, specify________ [ ] Without Cover
[ ] Drums
[ ] Pail
87
Water Storage for Cooking
[ ] Jug [ ] With Cover
[ ] Drum [ ] Without Cover
[ ] Bottles
[ ] Pail
[ ] Not Storing
[ ] Others, specify_______
Water Storage for General Household
[ ] Jug [ ] With Cover
[ ] Drum [ ] Without Cover
[ ] Bottles
[ ] Pail
[ ] Not Storing
[ ] Others, specify_______
Food Handling Type of Food Storage
[ ] Cooking [ ] Refrigerator [ ] Covered on Table
[ ] Buying [ ] Cupboard [ ] Sealed Container
[ ] Hanging in Basket [ ] others, specify________
[ ] Not Storing
Type of Refuse Container Method of Refuse Disposal
[ ] Garbage Cans [ ] With Cover Methods: [ ] Burning
[ ] Plastic [ ] Without Cover [ ] Burying
[ ] Sack [ ] Dumping
[ ] Pail [ ] Collected
[ ] Not Using [ ] Open pit
[ ] Others, specify_______ [ ] Others, specify________
Human Waste Disposal Toilet Ownership
[ ] Septic [ ] Solely owned
[ ] Semi Septic [ ] Shared, specify no. of families-
________
[ ] Pit privy
[ ] Latrine
[ ] Wrapped
[ ] Others, specify_______
HEALTH PROFILE
GROWTH MONITORING CHART (0 5 YEARS OLD)
No. With Without Reason
88
INFANT IMMUNIZATION (0 12 Months)
BCG
With Without
MEASLES (9 12 months)
89
With Without
No.
HEPA B
No. 1 2 3
With Without With Without With Without
DPT
No. 1 2 3
With Without With Without With Without
OPV
No. 1 2 3
With Without With Without With Without
NUTRITIONAL STATUS (0 5 years old)
No. Age in Months Weight in Kilograms Nutritional Status
90
ILLNESSES/DISEASESES (For the past 6 months)
No. Probable Confine Not Confined Herbal Remarks
Diagnosis d Used
DEATH IN THE FAMILY (For the past 5 years)
Probable Medical Attention
Year
Cause Yes No
FAMILY UTILIZATION OF HEALTH CENTER
[ ] USING
What program do you know? (check all that applies)
( ) Immunization ( ) Family Planning ( ) Prenatal Care
( ) Health Education ( ) TB DOTS Program ( ) Dental Health
( ) Others: ___________________________________________
[ ] NOT USING
Reason:
( ) Hospital ( ) Private Clinic
( ) Albularyo ( ) No one left at home
( ) Time restraint ( ) Not known to family
( ) Difficulty in travel ( ) Others, specify________________________
FAMILY PLANNING METHODS (COUPLES 15-49 YEARS OLD)
[ ] USING
Type:
( ) LAM ( ) Condom ( ) Standardized Base
Method
( ) Rhythm ( ) Diaphragm
( ) BBT ( ) Foam/Gel/Cream/Suppository
( ) DMPA ( ) BTL
( ) Pill ( ) Vasectomy
( ) CMM ( ) Others
[ ] NOT USING
Reason, specify:___________________________________________________________
ANTEPARTUM
Trimester: [ ] 1st [ ] 2nd [ ] 3rd
TETANUS TOXOID (Pregnant only)
[ ] With Dose: 1 2 3 4 5
[ ] Without
LIFESTYLE:
Number of Smokers in the Family
Smoking:______________________ Not Smoking: _____________________
CIGARETTE CONSUMPTION
NO DURATION CONSUMPTION
AGE
. Week Month Year Sticks Packs
Number of Alcohol Drinkers in the Family
Drinking:________________________________ Not Drinking:_________________
ALCOHOL BEVERAGE
FREQUENCY CONSUMPTION DURATION
NO. AGE Dail Occa- # of # of
Weekly Week Month Year
y sional Glasses Bottles
