Republic of the Philippines

Mindanao State University

College of Health Sciences
Marawi City

COMMUNITY HEALTH SURVEY FORM (OVERALL FREQUENCY AND PERCENTAGE)

I. FAMILY STRUCTURE, CHARACTERISTICS, AND DYNAMICS.

A. Type of family
Nuclear 3 60%
Extended 2 40%

B. Family Structure
Patriarchal 4 80%
Matriarchal 1 20%

C. Family Size
Small (1-4) 1 20%
Medium (5-6) 2 40%
Large (7 & up) 2 40%

D. Dominant family member in terms of decision-making, especially in matters of health care

Father 0 0%
Mother 5 100%

II. SOCIOECONOMIC AND CULTURAL CHARACTERISTIC

A. Employment Status
a. Mother
Unemployed 4 80%
Employed 0
Self-employed 1 20%

b. Father
Unemployed 1 20%
Employed 0 0%
Self-employed 4 80%

B. Monthly Income per Household

500-999 0 0%
1000-1999 1 20%
2000-2999 0 0%
3000-3999 2 40%
4000-4999 0 0%
5000-above 2 40%

C. Monthly Expenses per Household

500-999 0 0%
1000-1999 1 20%
2000-2999 1 20%
3000-3999 0 0%
4000-4999 1 20%
5000-above 2 40%
 Republic of the Philippines
Mindanao State University
College of Health Sciences
Marawi City

D. Adequacy to meet basic needs (food, shelter, clothing)

More than adequate 0 0%
Adequate 5 100%
Not Adequate 0 0%

E. Who makes decision about money and how it is spent?

Mother 3 60%
Father 1 20%
Both 1 20%

F. Ethnicity:
Maranao 5 100%

G. Religious affiliation:
Islam 5 100%

H. Relationship of the family in community activities

1. Attendance in social activities (weddings, funerals, etc)
Yes 5 100%
No 0 0%

2. Participation in political activities

Yes 5 100%
No 0 0%

3. Participation in healthcare activities

Yes 5 100%
No 0 0%

I. Educational Attainment (No formal education, Elementary level, Elementary Graduate, High
School level, High School graduate, College level, College graduate)
No Formal Education 7 21.875%
Elementary Level 10 31.25%
Elementary Graduate 1 3.125%
High School Level 5 15.625%
High School Graduate 2 6.25%
College Level 5 15.625%
College Graduate 2 6.25%

III. HOME AND ENVIRONMENT

A. Residency (Length of Stay)
Less than 6 months 5 100%
More than 6 months 0 0

B. Home ownership
Owned 3 60%
Rented 0 0
Rent-Free 2 40%
 Republic of the Philippines
Mindanao State University
College of Health Sciences
Marawi City

C. Land ownership
Owned 3 60%
Rented 0 0%
Rent-Free 2 40%

D. Type of House
Concrete 3 60%
Wood 0 0%
Concrete/Wood 2 40%
Makeshift 0 0%

E. Types of housing structure

Single-attached 3 60%
Single-detached 0 0%
Two-storey 2 40%
3-storey & up 0 0%

F. Electricity availability
With electricity 5 100%
Without electricity 0 0

G. Means of Cooking
Electricity stove 1 20%
LPG 3 60%
Wood/charcoal 3 60%
Kerosene 0 0%

H. Food Storage
With refrigerator 1 20%
Without refrigerator 4 80%

I. Water Source
Deep well 0 0%
Rainwater 3 60%
Communal 0 0%
Lake/River 5 100%
Distribution 0 0%

J. Storage of drinking water

With cover 5 100%
Without cover 0 0%

K. Garbage disposal
Compost pit 0 0%
Burning 5 100%
Collected 0 0%
Open dumping 0 0%
 Republic of the Philippines
Mindanao State University
College of Health Sciences
Marawi City

L. Type of toilet
Pit Latrine 0 0%
Pail System 0 0%
Septic tank/flush 5 100%

M. Drainage system
Open system 0 0%
Closed system 5 100%

N. Recreational Activities:
N/A 0 0%

O. Health Facilities:
Rural Health Unit 5 100%
District Hospital 5 100%

P. Communication Facilities
TV 0 0%
Cellphone 0 0%
Collected 5 100%

Q. Transportation facilities
Jeepney 0 0%
Tricycle 5 100%
Private Car 1 20%

IV. KNOWLEDGE OF PRIMARY HEALTH CARE CONCEPTS

Agree Disagree No Knowledge
Common illness such as TB can be avoided 5 0 0
Food rich in protein such as meat, fish & egg are needed 5 0 0
for growth and development
Headache, dizziness & edema are common signs of 5 0 0
pregnancy
Breast fed infants are healthier than bottle fed ones 5 0 0
Illnesses such as measles, poliomyelitis, diphtheria & 5 0 0
tetanus can be avoided through vaccination
OReSol is given to babies who have diarrhea 5 0 0
Family planning is good for maternal health 5 0 0
Herbal medicine is safe & causes no side effects even 5 0 0
when taken in excessive amounts
Blood-streaked sputum from coughing is a symptom of TB 5 0 0
Small cuts & contusions may be cleaned using soap and 5 0 0
tap water

V. HEALTH CARE
A. Person to consult when family members are sick
Doctor 0 0%
Nurse/Midwife 1 20%
 Republic of the Philippines
Mindanao State University
College of Health Sciences
Marawi City

Faith Healer 0 0%
Self-medication 4 80%

B. Type of Birth Attendants

Doctor 4 80%
Midwife 0 0%
Trained Hilot 1 20%

C. Place of Delivery
Private Hospital 0 0%
District Hospital 4 80%
Health Center 0 0%
House 1 20%

D. Infant Feeding Practices

Breast Feeding 3 60%
Bottle Feeding 1 20%
Mixed Feeding 1 20%

E. Use of Herbal Medicines

Lagundi 5 100%
Bawang 5 100%
Tsaang-Gubat 5 100%
Acapulco 0 0%
Luya 5 100%
Ampalaya 0 0%
Sambung 5 100%
Bayabas 5 100%

F. Height and Weight

Normal 14 66.67%
Overweight 0 0%
Underweight 7 33.33%

G. Immunization of the Children

Complete 2 9.52%
Incomplete 1 4.76%
Fully Immunized 18 85.71%

VI. RESPONSIBLE PARENTHOOD

A. Family Planning
Practicing FP 2 40%
Not Practicing FP 3 60%

B. Method used in Family Planning

IUD 0 0%
Pills 2 40%
Condoms 0 0%
BTL 0 0%
Rhythm 0 0%
 Republic of the Philippines
Mindanao State University
College of Health Sciences
Marawi City

Withdrawal 1 20%
Injection/DMPA 0 0%

VII. HEALTH AND MEDICAL RECORDS

A. Major Illnesses (Past and Present)
Hypertension 2 40%
DM 0 0%
Cardiac Disease 0 0%
PTB 0 0%
Pre-eclampsia 0 0%
Anemia 1 20%
Rheumatism 1 20%

B. Common Minor Illness

Fever 2 40%
Colds 1 20%
Headache 1 20%
Toothache 0 0%
Cough 1 20%

C. Cause of Death
Hypertension 5 100%
DM 1 20%
Cardiac Disease 0 0%
PTB 0 0%
Pre-eclampsia 0 0%
CVA 0 0%
Cancer 1 20%
Liver Disease 0 0%
Accident 0 0%

D. Hetero-Familial Diseases
Hypertension 5 100%
DM 2 40%
Cardiac Disease 1 20%
Cancer 1 20%
Epilepsy 0 0%
Asthma 3 60%
Rheumatism 2 20%
Mental Illness 0 0%

FIRST LEVEL OF ASSESSMENT

I- Presence of Health Threats

A. Presence or Family history of:
Diabetes Miletus 2 40%
Cancer 2 40%
Hypertension 5 100%
Cardiovascular Disease 2 40%
Rheumatism 1 20%
 Republic of the Philippines
Mindanao State University
College of Health Sciences
Marawi City

Asthma 1 20%

B. Presence of family members with communicable disease

Yes 3 60%
No 2 40%

C. Family size beyond what family resources can adequately provide

Yes 0 0%
No 5 100%

D. Presence of accident hazards

Broken Chairs 2 40%
Pointed/Sharp Objects 2 40%
Poisons and medicines improperly 0 0%
kept
Fire Hazards 0 0%
Fall Hazards 2 40%
Residence near river/lake 0 0%

E. Faulty/unhealthy nutritional or eating habits or feeding techniques or practices

Inadequate food intake both in 0 0%
quality and quantity
Excessive intake of certain 0 0%
nutrients
Faulty eating habits e.g. eating 1 20%
late, skipping meal and others
Ineffective breast feeding/faulty 1 20%
feeding techniques

F. Stress provoking factors

Strained marital relationship 1 20%
Strained parent-sibling 1 20%
relationship
Interpersonal conflicts between 1 20%
family members
Care giver burden 0 0%

G. Poor home/environment condition or sanitation

Inadequate living space 2 40%
Lack of food storage facilities 3 60%
Polluted water supply 0 0%
Presence of breeding or resting 3 60%
sights of vectors of diseases
Improper garbage disposal 5 100%
Poor lighting 3 60%
Poor ventilation 0 0%
Noise pollution 0 0%
Air pollution 0 0%

H. Unsanitary Food handling and preparation

Yes 0 0%
 Republic of the Philippines
Mindanao State University
College of Health Sciences
Marawi City

No 5 100%

I. Unhealthy lifestyle and personal habits/practices

Alcohol Drinking 0 0%
Cigarette/Tobacco smoking 3 60%
Walking barefoot 0 0%
Eating raw meat or fish 0 0%
Poor personal hygiene 1 20%
Substance abuse 0 0%
Sexual promiscuity 0 0%
Engaging in dangerous sports 0 0%
Inadequate rest or sleep 0 0%
Lack of inadequate 5 100%
exercise/physical activity
Lack of relaxation activities 0 0%
Non-use of self-protection 0 0%
measures (mosquito nets)

J. Inherent personal characteristics (e.g. short temper, poor impulse, control etc.)
Yes 0 0%
No 5 100%

K. Inappropriate role assumption (e.g. child assuming mother’s roe/father not assuming
his role)
Yes 0 0%
No 5 100%

L. Lack of immunization/inadequate immunization status of children

Yes 0 0%
No 5 100%

M. Presence of family disunity

Yes 0 0%
No 5 100%

II- PRESENCE OF HEALTH DEFICITS

(Instance of failure in health maintenance)
A. Presence of Illness (diagnosed or not)
Yes 4 80%
No 1 20%

B. Failure to thrive/develop according to normal process

Yes 0 0%
No 5 100%

C. Presence of disability (e.g. blindness, amputation, lameness from polio)

Yes 0 0%
No 5 100%

III- PRESENCE OF STRESS POINTS/FORESEEABLE CRISIS SITUATIONS

 Republic of the Philippines
Mindanao State University
College of Health Sciences
Marawi City

Marriage 0 0%
Pregnancy, labor, puerperium 0 0%
Parenthood 5 100%
Additional member (e.g., newborn, 3 60%
lodger)
Entrance at school 0 0%
Adolescent 1 20%
Divorce/separation 0 0%
Menopause 0 0%
Loss of job 0 0%
Hospitalization of a family 0 0%
Death of family member 0 0%
Resettlement in new community 0 0%