Fatima Community Diagnosis Tool

OUR LADY OF FATIMA UNIVERSITY ANTIPOLO College of Nursing Community Diagnosis Health Survey Tool

Head of the Family: _______________________________ Control No. ____________ (Kinikilalang puno ng pamilya) Complete Address: _________________________________________________________________ __________________________________________________________________________________ (Tirahan) pamilya) Length of Residency: _____________________________ ________________________________________________ (Tagal ng paninirahan sa lugar) Place of Origin: __________________________________ ________________________________________________ (Lugar na pinagmulan) Ethnic Background: _______________________________ (Etnikong grupo na kinabibilangan) Primary Dialect Spoken: ____________________________ (Pangunahing dialektong ginagamit)

No. of familiy members: (Bilang ng myembro ng Surveyed by: (Pangalan ng nag-survey) Date: (Petsa)

COMMUNITY AS A PEOPLE Family Structure, Characteristics, and Dynamics

No. (Blg.)

Name of Household Members (Pangalan ng miyembro ng pamilya)

Relationship to the Head of the Family (Kaugnayan sa puno ng pamilya)

Sex (Kasarian)

Date of Birth (m-dy-yr) (kapanganakan)

Age (Edad)

Civil Status (Estado sibil) *15 yrs. & above

Religion (Relihiyon)

Education (Antas ng Edukasyon) *7 yrs. & above Highest Educational Attainment Educational (PinakamaStatus taas na (Antas ng Antas ng Edukasyon) Edukasyong natapos)

Occupation (Hanapbuhay) *15-64 yrs. old

Type (Uri)

Place (Lugar)

Occupational Status (Kalagayan ng Trabaho)

LEGEND: M- Male

S- Single

C- Catholic

EG- Elem Grad

F- Female

M- Married W- Widowed

P- Protestant SA- 7th Day Adventist INC- Iglesia ni Cristo JW- Jehova’s Witness

EU- Elem Undergrad HG- High school Grad HU- High school Grad CU- College Undergrad V- Vocational

CL- Common law Sep- Separated

NF- No Formal Education PS- Presently Studying SS- Stopped Studying C- College Graduate

* specify highest educational attainment (PS)

1

Community as a Social System

( ) deep well ( ) artesian well ( ) local water system ( ) rain water ( ) streams, rivers, or spring

B. Political / Leadership Aspect (Requirement: opening 10% of floor area in sq.m.)

A. Economic Aspect a.

( ( ( (

Combined monthly family income (Buwanang kita ng pamilya)

) P1,000 and below ) P1,001 – P5,000 ) P5,001 – P10,000 ) P10,001 – P15,000

( ( ( (

) P15,001 – P20,000 ) P20,001 – P25,000 ) P25,001 – P30,000 ) P30,001 and above

b. Other sources of income (livelihood) (Mayroon pa bang ibang pinagkukunan ng kabuhayan?) * indicate the profit earned then add to the monthly family income ( ) Yes ( ) No If yes, what? (kung mayroon, ano?) ( ) sari-sari store ( ) poultry raising ( ) craft making ( ) livestock raising ( ) Others, pls. specify: _______________ c. Monthly family expenditure (Buwanang gastusin ng pamilya) ( ( ( (

) P1,000 and below ( ) P1,001 – P5,000 ( ) P5,001 – P10,000 ( ) P10,001 – P15,000 (

) P15,001 – P20,000 ) P20,001 – P25,000 ) P25,001 – P30,000 ) P30,001 and above

d. Priority expenditure, rank it 1-7 (1 is the highest, 7 is the lowest) _____ food (pagkain) _____ health (kalusugan) _____ house rental (upa sa bahay) _____ education (edukasyon) _____ electric bill (bayarin sa kuryente) _____ (clothing) _____ water bill (bayarin sa tubig) e. Resources allotted for health care (Nakalaang pondo para sa kalusugan) ( ) Yes

( ) No

a. Recognized leaders in the community (unang taong kinukunsulta at kinikilalang puno ng komunidad) ( ) Barangay officials ( ) Religious leaders ( ) Non-gov’t organizations ( ) elders ( ) Others, pls. specify: ____________________

( ) electricity ( ) kerosene ( ) candles ( ) Others, pls. specify: _______________ _____ adequate

Level ( ) Level I ( ) Level II ( ) Level III

_____ inadequate

f. Excreta Disposal (Uri ng palikuran) b. Community Program (Ano ang mga alam na programa sa komunidad?) ( ( ( (

) peace and order ( ) fumigation ) curfew ( ) tapat ko linis ko ) sportsfest ) Others, pls. specify: ____________________

c. Predominant organizations in the community (Kilalang samahan sa komunidad) ( ( ( ( (

) Barangay Council ) Sangguniang Kabataan ) Couples for Christ ) Seniors Citizens Club ) Others, pls. specify: _____________________

( ( ( (

) pail system ) flush type ) bored hole latrine ) overhung latrine

( ) open pit ( ) closed pit ( ) water-sealed

o. Storage of drinking water (imbakan ng inuming tubig) ( ) jar (banga) ( ( ) bottles ( ( ) water tank ( ______ covered

g. Sanitary condition of toilet facility ( ) good ( ) fair

) plastic/glass container ) drum ) water dispenser ______ uncovered

( ) poor

h. Ownership of toilet facilities (pagmamay-ari ng palikuran) ( ) private (sariling gamit) ( ) shared (may kahati sa gamit) ( ) public (gamit pambayan) i. Sewerage system of the family (Uri ng kanal ng pamilya)

d. Traditions celebrated, observed in the community

( ) blind drainage none

( ) Fiesta ( ) Thanksgiving ( ) Holy Week ( ) Others, pls. specify: _____________________

j. Condition (kalagayan ng daloy ng tubig sa kanal)

( ) open drainage

( )

p. Method commonly used in sanitizing water (Paraang ginagamit upang mapanatiling malinis ang inuming tubig) ( ) boiling (pagpapakulo) ______ for how long? (gaano katagal?) ( ) filtration (pagsasala) ( ) sedimentation (pagpapalatak) ( ) Others, pls. specify: _______________

q. Domestic animals upkeep (dogs & cats only) ( ) free flowing

C. Environmental Aspect

( ) stagnant

a. Land ownership (Pagmamay-ari ng lupang tinitirahan)

k. Type of garbage disposal used (Uri ng pagtatapon ng basura)

( ) owned ( ) rented ( ) lease to own ( ) rent free ( ) Others, pls. specify: __________________________________________

( ) animal feed ( ) composting ( ) open dumping ( ) burial pit ( ) burning ( ) garbage collection( ) Others, pls. specify: _______________________

b. House ownership (Pagmamay-ari ng bahay na tinitirahan) ( ) owned ( ) rented ( ) lease to own ( ) rent free ( ) Others, pls. specify: __________________________________________

If yes, from where? (kung oo, galing saan?)

e. Lighting – facilities

c. Type of materials used for house (Uri ng materyales ng bahay) ( ) Health Insurance ( ) SSS, GSIS ( ) Phil. Health ( ) savings ( ) Others, pls. specify: _______________

( ) light ( ) mixed ( ) strong ( ) makeshift (barong

l. Waste garbage segregation _____ Yes _____ No m. Container used for garbage ( ( ( (

) garbage bag ) waste basket ) sac ) none

______ covered

______ uncovered

Kind (Uri)

Num ber (Bila ng)

Place kept (pinaglalag yan)

Vaccination (Bakuna sa hayop) With Without (mayro (wala) on)

r. Presence of vectors and rodents (pagkakaroon ng peste sa bahay) ( ) flies (langaw) ( ) termites (anay) ( ) rats (daga) ( ) mosquitoes (lamok) ( ) roaches (ipis) ( ) Others, pls. specify: _______________________________________

s. Presence of breeding sites of vectors (pagkakaroon ng lugar na pinamamahayan ng mga peste)

barong) n. Source of drinking water (pinanggagalingan ng inuming tubig)

d. Ventilation ( ) well ventilated ventilated

2

( ) fair

( ) poorly

( ) commercially prepared water

______ with ______ without If with, specify location ___________________

t. Ways of controlling of vectors (paraang ginagawa upang mapuksa ang mga peste sa bahay) ( ( ( ( ( (

3

) fumigation (pagpapausok) ) mouse trap ) fly traps ) insecticides (pamatay insekto i.e. katol) ) screens on doors and windows (i.e. kulambo) ) Others, pls. specify: ___________



e. First person consulted in times of illness (Unang taong kinukunsulta tuwing may magkakasakit)

D. Health Aspect



a. Community health programs (programang pangkalusugan) Aware (alam)

Utilizes (nagkukunsulta)

_____

_____

_____

_____

_____

_____

_____

_____

_____

_____

( ) Free consultation (libreng konsulta) ( ) Immunization (libreng bakuna) ( ) Family Planning (Programa sa pagpaplano ng pamilya) ( ) Pre-natal check-up (Programa para sa buntis) ( ) Well-baby clinic (konsulta para sa mga sanggol na bata)

( ( ( ( ( (

) doctor ( ) albularyo ) midwife ( ) relatives ) nurse ( ) faith healer ) family ( ) BHW ) hilot ) Others, pls. specify: _______________



h. Infant feeding program ( ( ( (

f. Medications taken during illness (gamot na iniinom) ( ) prescribed ( ) herbal ( ) over the counter ( ) Others, pls. specify: _______________

Name

Age

Acceptor

Nonacceptor

_____ condensed milk _____ evaporated milk _____ powdered milk _____ others, pls. specify: ____________

Method i. Maternal Care (Pangangalaga sa buntis)

Practiced

Not practiced

Use of hygienic products Sleep 6-8 hrs a day Brushes teeth Cuts toenails Cleans ears Changes clothes Eats balanced diet Smoking Regular exercise Use of prohibited drugs Dental check-up Drinking alcoholic beverages Medical check-up Recreational Relaxation Activities

Frequency

Nam e (pan gala n) Legend: r- rhythm b- basal body temp

*indicate the name of the member c. Food usually eaten (madalas na kinakain) *majority of the family members ( ( ( ( (

) fish ) meat ) vegetable ) mixed ) Others, pls. specify: _______________

d. Food storage practices (Pangangalaga sa pagkain)

c- cervical mucus method g.1. Natural ( ( ( (

) rhythm ( ) cervical mucus method ) withdrawal ) basal body temperature ) Others, pls. specify: _______________

g.2. Artificial contraceptives ( ) condoms ( ) IUD ( ) Others, pls. specify: ______________

( ) refrigerator ( ) table ( ) basket ( ) Others, pls. specify: _______________ g.3. Permanent _____ covered

_____ uncovered ( ) vasectomy ( ) tubal ligation

 For items h-k: Answer only if applicable

4

) breast milk ) formula ) mixed ) Others, pls. specify: _______________

Formula used: g. Method of family planning (pagpaplano ng pamilya) *applicable to members of reproductive age (15-44 yrs. old)

b. Family Health Practices Health Practices

h and i – If there are children 0-12 mos. in the family j – If there are children 0-83 mos. (0-7 yrs) in the family k – If there is a pregnant member of the family

( ) pills

No. of preg nanc y (bila ng ng pang anga nak)

Age of Gestation (bilang ng buwan ng pagbubunt is)

Expecte d date of delivery (inaasa hang petsa ng pangan ganak)

Prenata l Checkup

Wi th

W it h o u t

Tetanus Toxoid Immunization *indicate how many dosage

T I 1

T I 2

TI 3

TI 4

TI 5

j. Immunization Status of Target Age Group (0-12 mos.) DPT

Name

Age in Mos.

BCG

1

OPV

2

3

1

2

Hepatitis B

3

1

2

Remarks

3

AMV

Incomplete (applicable to 0-12 mos.)

Complete (applicable to 0-9 mos.)

fullyimmunized (applicable to 9-12 mos.)

k. Morbidity (w/in 1 whole year) * Jan 1 – Dec 31 Name (pangalan)

Age (edad)

Sex (kasarian)

Intervention (Medication/Hospitalization) with without

l. Mortality (w/in 1 whole year) * Jan 1 – Dec 31 Name (pangalan)

Age (edad)

Sex (kasarian)

Cause of death (dahilan ng pagkamatay)

m. Blood pressure (18 yrs. & above)

Name (pangalan)

5

Age (edad)

Sex (kasarian)

BP reading

Familial history of hypertension

Risk Factors Diet (high fat/high salt)

Exercise

Smoking

Alcohol drinking