Colegio de San Juan de Letran-Calamba

School of Nursing
COMMUNITY SURVEY FORM

I. BACKGROUND INFORMATION DATE: January 12, 2009

Family Name: Hernandez Usual source of Medical Care: Health Center
Family Structure: Nuclear Family Place of Origin: Camarines Sur
Family Stage: Beginning Family Nationality (if foreign): Filipino
Years of Residency: 4 years Religion: Roman Catholic
Profile

Educational
Relation to the Civil Monthly
Name Sex Age Occupation Attainment/ Religion
Family Head Status Earning
Background
Cyril Hernandez Mother F 20 Housewife Highschool Catholic Married N/A
undergraduate
Efren Hernandez Father M 29 Driver Highschool Catholic Married 5, 600
undergraduate
John Kenneth Son M 9 N/A Grade School Catholic Single N/A
Hernandez
Note: indicate if pregnant woman – AOG, EDC, GP, TT received

For children 0-5 years old)

Type of feeding (BF, Immunization (fully

Educational
Name Age Sex Weight Height Bottled Fed, Mixed, immunized;incomplete/
level
Supplementary) defaulter)(0-1yr.)
- - - - - - - -
- - - - - - - -
- - - - - - - -
- - - - - - - -
- - - - - - - -

B. Health Condition for the past year (only if with deviation from normal)
Treatment
Name of sick
Ailment Date of Occurrence a. Procedures Present Condition
member
b. Medications

C. Deceased Family Member (if applicable) – for the past year

Name of Deceased Cause of Death Date Died

II. ENVIRONMENTAL STATUS

A. HOUSING
1. Type 4. Rooms
_ Strong (concrete) _ _1
____ Light (wood) √_ 2
__√___ Mixed (concrete, wood) ___3 or more
______ Others (specify)

2. Ventilation 5. Ownership
__ _ Well ___ rented
√__ Poor _√ _ owned
_____ others (specify)

3. Lighting 6. Overall impression of the house and

Well surroundings (to be answered by surveyor)
_√__ Poor *The house itself have dust particles on the surface.

Source: _ √ electricity
__ _kerosene
____others (specify)

B. WATER
1. Source of Water Supply
____ _NAWASA __ √ __ deep well ____________ Water refilling station
(If NAWASA choose whether)
a. Owned b. Communal

2. Storage
___√__ container ______ covered ______ uncovered

3. Distance from House: _10 meters_

C. EXCRETAL DISPOSAL
1. Toilet Facility
YES () NO ( )
____√____Water Sealed _________”balot” system (wrap & throw)
_________Open pit _________sewerage system
_________Hanging toilet _________others (specify)
_____ __Flush
_________others (specify)

D. GARBAGE DISPOSAL
1. Method of Disposal
 _________open pit ____√____garbage collector _________burning

E. FOOD ESTABLISHMENT (if any within community)

Permit: YES ( ) NO ( )
1. Establishment
________sari-sari store ________carinderia
________ambulant vendor _________talipapa
_________others (specify)

2. Storage: How?
F. DRAINAGE SYSTEM: ___√_ __ open _______blind/closed _________none
_____ __ good
____√ __ poor (specify)
G. ANIMALS RAISED
1. Type/Kind
____√___domestic (specify) ___Cat____
____ ____stray (specify) _______ _
H. APPLIANCES OWNED
_________vehicles, type________
___ _____refrigerator ____ ____electric fan
___ _√___TV ________oven/stove
________VCR ________washing machine
___ ____stereo/radio ________video camera
___ ____computer _____ ___sofa
_________LD/CD _________others: (specify)
I. COMMUNICATION FACILITIES
____ √____cell phone
________telephone (nakikitawag)
____ ___radio
J. ACCESSIBILITY TO COMMUNICATION FACILITY (hospital, market, school, church, etc.)

III. NUTRIONAL STATUS

A. FOOD PREFERENCES (general)

____√____vegetables ____√____pork ____√___beef
____√____poultry (chicken) ____√____fish
____√____beverages
____√ ___water _________soft drinks _________juices

How much intake/day of these beverages

______1-3x __√_ __4-6x ____7-9x ______10x or more
 No. of meals/ day
______once ______twice ____thrice ______four or more

B. WAYS AND MEANS OF FOOD PREPARATION

____ √___prepared at home ____√____instant meals
_________street foods (i.e. ihaw, fish ball etc) _________bought (specify)
_________others (specify)
IV. OTHER INFORMATION

A. PERSONAL HABITS
NAME:
Smoking: (√ ) No ( ) Yes _ _packs/day
Alcohol: (√ ) No ( ) Yes __ bottles/day
Drugs: (√ ) No ( ) Yes
Note: indicate frequency distribution

B. EXERCISE
(√) Yes
( ) No
C. CIVIC INVOLVMENT
1. Organization/s: none
2. Participation in Health Care Action: none
3. Position in the Community/Organization: none
D. PREFERRED MEDICINES
___√____OTC ____ ___PRESCRIBED _______Herbal Medicines (specify)

E. FAMILY PLANNING
( ) YES (√ ) NO
____ __method _______defaulter
________active user
F. HEALTHCARE FACILITIES
____√___BHS ________Private Clinics ____ ___Hospital
G. BELIEFS AND PRACTICES
(√) YES (specify) ( ) NO
H. COMMUNITY PROBLEMS
1. Garbage Disposal
2. Relationship/Unity with their neighbors
3. Source of water
4. Source of income

Colegio de San Juan de Letran-Calamba

 School of Nursing
COMMUNITY SURVEY FORM

I. BACKGROUND INFORMATION DATE: January 12, 2009

Family Name: Mallari Usual source of Medical Care: Health Center
Family Structure: Extended Family Place of Origin: Camarines Sur
Family Stage: Nationality (if foreign): Filipino
Years of Residency: 45 years Religion: Roman Catholic
Profile

Educational
Relation to the Civil Monthly
Name Sex Age Occupation Attainment/ Religion
Family Head Status Earning
Background
Victoria Mallari Mother F 45 Housewife Highschool Catholic Married N/A
undergraduate
Christino Mallari Father M 51 Magbobote Highschool Catholic Married 3, 000
undergraduate
Arman Mallari Son M 21 None Highschool Catholic Single N/A
undergraduate
Note: indicate if pregnant woman – AOG, EDC, GP, TT received

For children 0-5 years old)

Type of feeding (BF, Immunization (fully

Educational
Name Age Sex Weight Height Bottled Fed, Mixed, immunized;incomplete/
level
Supplementary) defaulter)(0-1yr.)
- - - - - - - -
- - - - - - - -
- - - - - - - -
- - - - - - - -
- - - - - - - -

B. Health Condition for the past year (only if with deviation from normal)
Treatment
Name of sick
Ailment Date of Occurrence a. Procedures Present Condition
member
b. Medications

D. Deceased Family Member (if applicable) – for the past year

Name of Deceased Cause of Death Date Died

II. ENVIRONMENTAL STATUS

A. HOUSING
1. Type 4. Rooms
 _ Strong (concrete) _ √_ 1
____ Light (wood) _2
__√___ Mixed (concrete, wood) ___3 or more
______ Others (specify)

2. Ventilation 5. Ownership
__ _ Well ___ rented
√__ Poor _√ _ owned
_____ others (specify)

3. Lighting 6. Overall impression of the house and

Well surroundings (to be answered by surveyor)
_√__ Poor *The house itself have dust particles on the surface.

Source: _ √ electricity
__ _kerosene
____others (specify)

B. WATER
1. Source of Water Supply
____ _NAWASA __ √ __ deep well ____________ Water refilling station
(If NAWASA choose whether)
b. Owned b. Communal

4. Storage
_____ container ___√__ covered ______ uncovered

5. Distance from House: _10 meters_

C. EXCRETAL DISPOSAL
1. Toilet Facility
YES () NO ( )
____√____Water Sealed _________”balot” system (wrap & throw)
_________Open pit _________sewerage system
_________Hanging toilet _________others (specify)
_____ __Flush
_________others (specify)

D. GARBAGE DISPOSAL
1. Method of Disposal
_________open pit ____√____garbage collector _________burning
E. FOOD ESTABLISHMENT (if any within community)
Permit: YES ( ) NO ( )
1. Establishment
________sari-sari store ________carinderia
________ambulant vendor _________talipapa
_________others (specify)

2. Storage: How?
F. DRAINAGE SYSTEM: ___√_ __ open _______blind/closed _________none
_____ __ good
____√ __ poor (specify)
G. ANIMALS RAISED
1. Type/Kind
_______domestic (specify) __________
____ ____stray (specify) _______ _
H. APPLIANCES OWNED
_________vehicles, type________
___ _____refrigerator ____ ____electric fan
___ _√___TV ________oven/stove
________VCR ________washing machine
___ _√__stereo/radio ________video camera
___ ____computer _____ ___sofa
_________LD/CD _________others: (specify)
I. COMMUNICATION FACILITIES
____ √____cell phone
________telephone (nakikitawag)
____ ___radio
J. ACCESSIBILITY TO COMMUNICATION FACILITY (hospital, market, school, church, etc.)

III. NUTRIONAL STATUS

A. FOOD PREFERENCES (general)

____√____vegetables ____√____pork ____√___beef
____√____poultry (chicken) ____√____fish
____√____beverages
____√ ___water ___√ __soft drinks _________juices

How much intake/day of these beverages

___√__1-3x ___ __4-6x ____7-9x ______10x or more
No. of meals/ day
______once ______twice __√_thrice ______four or more
B. WAYS AND MEANS OF FOOD PREPARATION
____ √___prepared at home ________instant meals
_________street foods (i.e. ihaw, fish ball etc) _________bought (specify)
_________others (specify)
IV. OTHER INFORMATION

A. PERSONAL HABITS
NAME:
Smoking: (√ ) No ( ) Yes _ _packs/day
Alcohol: (√ ) No ( ) Yes __ bottles/day
Drugs: (√ ) No ( ) Yes
Note: indicate frequency distribution

B. EXERCISE
(√) Yes
( ) No
C. CIVIC INVOLVMENT
1. Organization/s: none
2. Participation in Health Care Action: none
3. Position in the Community/Organization: none
D. PREFERRED MEDICINES
___√____OTC ____ ___PRESCRIBED _______Herbal Medicines (specify)

E. FAMILY PLANNING
( ) YES (√ ) NO
____ __method _______defaulter
________active user
F. HEALTHCARE FACILITIES
____√___BHS ________Private Clinics ____ ___Hospital
G. BELIEFS AND PRACTICES
(√) YES (specify) ( ) NO
H. COMMUNITY PROBLEMS
1. Garbage Disposal
2. Human waste disposal
3. Source of water
4. Source of income