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Community Health Survey Form

This document is a community health survey form used to collect information on households in a community. It collects data on the household head, family members, housing conditions, water and sanitation facilities, healthcare access, common illnesses, and more. The form is used to assess overall community health and identify areas for improvement.

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Arvin Jon Bislig
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© Attribution Non-Commercial (BY-NC)
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Download as DOCX, PDF, TXT or read online on Scribd
3K views

Community Health Survey Form

This document is a community health survey form used to collect information on households in a community. It collects data on the household head, family members, housing conditions, water and sanitation facilities, healthcare access, common illnesses, and more. The form is used to assess overall community health and identify areas for improvement.

Uploaded by

Arvin Jon Bislig
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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COMMUNITY HEALTH SURVEY FORM

Head of the Family:_____________________________________ House No.:____ Date Assessed:_______


No. Family Member Name Relation to Head Sex Age Marital Status Educational Attainment Occupation Monthly Income

No.

NAME

CHILDRENS IMMUNIZATION AGE SEX BCG DPT

OPV

HEPA B

MEASLES

1. Type of Family: [ ] Nuclear [ ] Extended [ ] others, specify: ____________ 2. Home: Ownership: [ ] Owned [ ] Rented [ ] others, specify: ____________ Construction materials used: [ ] Wood [ ] Mixed [ ] Concrete [ ] others, specify: ___________ Numbers of rooms used for sleeping: _______ Lighting Facilities: [ ] Electricity [ ] Kerosene [ ] others, specify: ____________ General Surroundings: [ ] Clean [ ] Dirty 3. Water Supply: Source: [ ] Artesian well [ ] Deep well [ ] MAWASA [ ] others, specify: ____________ Storage of Drinking Water: [ ] Covered [ ] Uncovered [ ] Refrigerated [ ] others, specify:______ Sanitary Condition: ____________________ Kitchen: Cooking Facility: [ ] Electric Stove [ ] Gas Stove [ ] Firewood/Charcoal Sanitary Condition: ______________ Drainage Facility: [ ] Open [ ] Blind [ ] None 4. Domestic Animals KIND NUMBER WHERE KEPT

5. Pest / Insect: [ ] Mosquito

[ ] Lizards

[ ] Flies

[ ] others, specify:_____

6. Garbage Disposal Container: [ ] Covered [ ] Open [ ] None Method of Disposal: [ ] Hog Feeding [ ] Open Burning [ ] Open Dumping [ ] Garbage Collection [ ] Burial in Pit [ ] Composting [ ] others, specify: _____________ 7. Toilet Facility Sanitary: [ ] Flush Type [ ] Pit Privy / Communal ( ) with septic tank Ownership: [ ] Owned [ ] Shared Unsanitary: [ ] Ballot System [ ] others, specify: _____________ 8. Nutrition Food Preference: [ ] Meat [ ] Fish [ ] Fruits/Vegetables [ ] Mixed Common Food: [ ] Rice and Egg [ ] Rice and Noodles [ ] Rice and Sardines [ ] others, specify: ______________ 9. Food Storage [ ] Covered [ ] Uncovered [ ] Refrigerated [ ] others, specify: _________ 10. Gardening [ ] Fruit Bearing [ ] Vegetables [ ] Herbal [ ] others, specify: ________________ 11. Whom do you consult in time of illness? [ ] Private [ ] Rural Health Midwife [ ] Traditional, e.g. Herbularyo [ ] Others, specify: ______________ 12. Common illness encountered within 6 months: [ ] Malaria [ ] Amoebiasis [ ] Influenza [ ] Dengue Fever [ ] Tuerculosis [ ] Asthma [ ] Typhoid Fever [ ] others, specify: __________ 13. Plan to utilize Health Service: [ ] Hospital [ ] Health [ ] Clinic [ ] others, specify: ____________ 14. Do you utilize your Health Center? [ ] Yes [ ] No 15. Reasons for utilizing Health Center: [ ] Post Natal [ ] Pre Natal [ ] Immunization [ ] Morbidity [ ] Health Counselling [ ] others, specify: ______________ 16. Environment Kind of Neighborhood Social and Health Facilities Available Communication and Transportation Available Assessed by:

________________________________ Students Signature over Printed Name

Noted by:

GLORIA N. RAMOS, M.A.N Clinical Instructor

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