Community Survey

COLLEGE OF NURSING & MIDWIFERY Dasmariñas, Cavite COMMUNITY SURVEY FORM

I. BACKGROUND INFORMATION: Family Name: Cabling Family Structure: Extended Family Stage: Pre-school stage Years of Residency: A. Profile Rel. to the Family

Sex

Remedios Honrada

Grandmother

Cesar Cabling Analiza Cabling

Name

Name Bernadette Cabling

Anne

Beverly Joy Cabling

1 year; Lola Remedios (30 yrs.) Place of Origin: Cavite Nationality: Filipino Religion: Roman Catholic Religio n Roman Catholic Ramon Catholic

Widow

Roman Catholic

Marrie d

F

Ag e 62

Occupati on None

1st year HS

Father

M

35

OFW

College Grad.

Mother

F

29

Housewife

High school Graduate

Ag e 3

Se x F

Weigh t 12 kg

1

F

8 kg

Civil Stat us

Education al Level

Nut. Status Midline between undernourished and normal Normal

Marrie d

Monthl y Earning P 13, 000.00 max

Type of Feeding 1 mo. Breastfeed ; Bottle feed

Immunizat ion Complete

Educ’t Level None

Bottle feed

Complete

None

B. Health Condition for the Past Year Name of Sick Member

Ailment

Date Occurrence

Nanay Remedios

Hypertension

November 2008

Bernadette Anne

Cough and Cold

February 2009

of

Treatment a. Procedures b. Medications Consulted Doctor No Medications None

Present Condition Normal BP Normal

II.

ENVIRONMENTAL STATUS A. Housing 1. Type: Strong 2. Ventilation: Poor 3. Rooms: 1 4. Ownership: Rented 5. Lighting: Well a. Source: Electricity B. Water 1. Supply/ Source: Deep Well Distance from the house: a meter 2. Storage: Covered Container C. Excretal Disposal 1. Toilet Facility: Yes Water Sealed/ Flush D. Garbage Disposal 1. Method of Disposal: Garbage Collector E. Food Establishment Permit: None 1. Establishment: Sari-sari Store Carinderia, F. Drainage System: Open G. Animals Raised 1. Type/ Kind: Domestics; Rooster H. Appliances & Transportation Facility Owned TV

6. House is small, made of concrete no ceiling and hot during afternoon. No paint and the floor serve as bed, dining table and sitting area.

Ambulant Vendor 2. Storage: Plastic

Sofa

I.

Electric Fan Stove Accessibility to Community Facilities: Yes

Radio Washing Machine

III. Nutrition A. Food Preferences Vegetables No. of Snacks/day: 2 Pork No. of glasses consume/day: 8 Chicken Juice Fish Water No. of Meals/day: 3 Coffee B. Ways and Means of Food Preparation (most of the time) Prepared at house IV. OTHER INFORMATION A. Personal Habits Smoking, Drinking, Street Drugs: None B. Exercise: Walking; frequent C. Membership to Organization: None D. Usual Source of Medical Care Hospital, BHS, Traditional Practitioners, Combined: Hospital and Trad. Med E. Preferred Medicines: Prescribed, Herbal Medicine