COLLEGE OF NURSING & MIDWIFERY

Dasmariñas, Cavite

COMMUNITY SURVEY FORM

I. BACKGROUND INFORMATION:
Family Name: Cabling 1 year; Lola Remedios (30 yrs.)
Family Structure: Extended Place of Origin: Cavite
Family Stage: Pre-school stage Nationality: Filipino
Years of Residency: Religion: Roman Catholic
A. Profile
Civil Monthl
Rel. to the Ag Occupati Education Religio Stat y
Name Family Sex e on al Level n us Earning
Remedios Honrada Grandmother F 62 None 1st year HS Roman Widow
Catholic
Cesar Cabling Father M 35 OFW College Grad. Ramon Marrie P 13,
Catholic d 000.00
max
Analiza Cabling Mother F 29 Housewife High school Roman Marrie
Graduate Catholic d

Name Ag Se Weigh Nut. Status Type of Immunizat Educ’t

e x t Feeding ion Level
Bernadette Anne 3 F 12 kg Midline between 1 mo. Breastfeed Complete None
Cabling undernourished and ; Bottle feed
normal
Beverly Joy Cabling 1 F 8 kg Normal Bottle feed Complete None

B. Health Condition for the Past Year

Name of Sick Member Ailment Date of Treatment Present
Occurrence a. Procedures Condition
b. Medications
Nanay Remedios Hypertension November 2008 Consulted Doctor Normal BP
No Medications
Bernadette Anne Cough and Cold February 2009 None Normal

II. ENVIRONMENTAL STATUS

A. Housing
1. Type: Strong
2. Ventilation: Poor 6. House is small, made of
3. Rooms: 1 concrete no ceiling and hot
4. Ownership: Rented during afternoon. No paint
5. Lighting: Well and the floor serve as bed,
a. Source: Electricity dining table and sitting area.
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 Ambulant Vendor
Carinderia, 2. Storage: Plastic
F. Drainage System: Open
G. Animals Raised
1. Type/ Kind: Domestics; Rooster
H. Appliances & Transportation Facility Owned
TV Sofa
 Electric Fan Radio
Stove Washing Machine
I. Accessibility to Community Facilities: Yes
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