COMMUNITY HEALTH SURVEY TOOL

I. Household Members

Surname Given Middle Age Sex Family Relation Birth Civil Highest Occupation Immunizatio Literacy Remarks
Name Initial Position to the Date Status Educational and Daily/ n Status Status
(ordinal) Head Attainment Monthly
Salary
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Put * after the surname of deceased individual. Write the cause and place of death under the remarks column. In addition, note down in the same column any health
abnormalities of the above individuals indicating in terms of prenatal, postpartum, mentally retarded, morbid case (specify present illness), malnourished, and overweight.
Indicate the place of birth for neonates. Mark (x) if not immunized, C for complete and (?) if not known. Place “O.S.” if out of school then write the reason under the column
remarks. Use the term employed, retired, and unemployed for their occupational status. Indicate the literacy status whether literate (can read and write) or illiterate.

II. Length of Residency _______

III. Religion/Sect ( ) Roman Catholic ( ) Mormon ( ) Seventh Day Adventist ( ) Others (specify): _________

( ) Born Again Christian ( ) SAKSI ( ) Islam

IV. Place of Origin ( ) Region I ( ) Region III ( ) Region V ( ) Region VII ( ) Region IX ( ) Region XI ( ) CAR ( ) Region II ( ) Region IV
( ) Region VI ( ) Region VIII ( ) Region X ( ) Region XII ( ) CARAGA
( ) ARMM ( ) Abroad (specify): _________
 Specify the province: ___________

V. Medium of Communication (Sending and Receiving of Information) ( ) Cell phone ( ) Radio ( ) Landline ( ) Television

VI. Transportation Facility ( ) Pedicabs/Bicycle ( ) Motorbike ( ) Tricycle ( ) Jeep ( ) Bus ( ) Taxi/FX

VII. Accident Hazards ( ) None ( ) Broken Stairs ( ) Poisons ( ) Pointed/Sharp Objects ( ) Fire hazards ( ) Fall Hazards

( ) Others (specify): ____________

VIII. Ethnicity ( ) Bicolano ( ) Ibanag ( ) Ilocano ( ) Ivatan ( ) Kapampangan ( ) Moro

( ) Pangasinense ( ) Sambal ( ) Tagalog ( ) Visayan ( ) Tribal Group (specify): ______________

IX. Language/Dialect Spoken ( ) Agta ( ) Ayta ( ) Bagobo ( ) Bantuanon ( ) Bikolano ( ) Bolinao ( ) Cebuano ( ) Chavacano

( ) Davaweno ( ) Dumagat ( ) Filipino ( ) Hiligaynon ( ) Ifugao ( ) Ilocano ( ) English ( ) Manobo

( ) Masbateno ( ) Pampangan ( ) Pangasinan ( ) Others (specify): ________________

X. What are your health beliefs and practices? 1. _________________________________________________________

2. _________________________________________________________

3. _________________________________________________________

XI. What are your concepts about health 1. _________________________________________________________

and illness? 2. _________________________________________________________

3. _________________________________________________________

XII. Income Total / Month (Check the bracket)

( ) Below Php. 5,000.00

( ) Php. 5,100.00 – Php. 10,000.00

( ) Php. 10,100.00 – Php. 15,000.00

 ( ) Php. 15,100.00 – Php. 20,000.00

( ) Php. 20,100.00 – Php. 30,000.00

( ) Php. 30,100.00 – Php. 40,000.00

( ) Php. 40,100.00 – Php. 50,000.00

XIII. Agency Utilized for Seeking Health Care ( ) Barangay Health Station ( ) Rural Health Unit ( ) Hospital

XIV. Social and Health Facility ( ) Basketball court ( ) Social Hall ( ) Barangay Hall ( ) Health Center ( ) Market ( ) Hospital

XV. Housing

a. Type of House ( ) Strong ( ) Wood ( ) Mixed ( ) Light ( ) Makeshift

b. Ownership ( ) Owned ( ) Rented ( ) Rented Free

c. Ventilation ( ) Satisfactory ( ) Fair and Below Poor

d. Overcrowding ( ) Overcrowded ( ) Not Overcrowded/Living Space Adequate

XVI. Environment

a. Water Supply ( ) Point Source (Level I) ( ) Communal Faucet System (Level II) ( ) Water Works System or Individual House connections (Level III)

b. Excreta Disposal ( ) Water-sealed Latrine/Hand-flushed ( ) Septic Tank ( ) Balot System or Wrap and Throw ( ) Pit Privy

( ) Others (specify): ___________

c. Garbage Disposal ( ) Collected ( ) Animal Feeding ( ) Composting ( ) Burial Pit ( ) Recycling

( ) Burning ( ) Burying) ( ) Open Dumping

d. Income Status ( ) High Income Group ( ) Moderate Income Group ( ) Low Income Group

XVII. Industry ( ) Mining ( ) Farming ( ) Refining ( ) Construction ( ) Manufacturing ( ) Others (specify): ______________
XVIII. Pollution ( ) None ( ) Air ( ) Water ( ) Land

XIX. Government Programs Being Utilized ( ) Family Health: ________________________________________________________________

( ) Non-Communicable Disease Prevention and Control: ____________________ _____________

( ) Communicable Disease Prevention and Control: _____________________________________

( ) Environmental Health and Sanitation: _____________________________________________

( ) Others (specify): ______________________________________________________________

The following initials/codes can be used:

Family position: F = father GF = grandfather H = housekeeper

M = mother GM = grandmother
S = son U = uncle
D = daughter A = aunt

Civil Status: M = married Cause of Death: HD = heart disease

S = single VSD = vascular system disease
W = widow MN = malignant neoplasm
Sep. = separated A = accident
CL = common-law P = pneumonia
TB = tuberculosis
CLRD = chronic lower respiratory disease
Educational Attainment: CG = College graduate DM = diabetes mellitus
CL = In undergraduate level, indicate what level PC = perinatal complication
HG = High school graduate U = unknown cause
HL = High school undergrad O = others (specify)
EG = Elementary graduate Based on: MORTALITY: TEN LEADING CAUSES BY SEX
 EL = Elementary level Number, Rate/100,000 Population and Percent Distribution Philippines, 2004
K = Kindergarten
P = Prep
N = Nursery
Ventilation: 1. Determine the total floor area in meters (TFA). Overcrowding: 1. Determine the size of the living space or the total floor area
2. Get the area of the window or the window opening in meters (WO). (TFA). This is done by estimating and multiplying the length and
WO = length of the window x its width – L x W the width of a multi-purpose area.
3. Apply the formula: TFA = L x W in meter
Ventilation = TWO/TFA x 100 2. Determine the total space requirements of the family (TSR).
4. Foe the state of ventilation, consider the following scale: Each member has his own space requirement (ISR).
20% - satisfactory 18-19% - fair and below poor

Multi-purpose room Single-purpose room

Adult 3 sq.m. 2.5 sq.m.
Children 1.5 sq.m. 1.26 sq.m.
Infants 0 0