CENTRO ESCOLAR UIVERSITY

College of Nursing
Makati

COMMUNITY SURVEY TALLY FORM

2nd Semester, School Year 2007-2008

Tally Number of Household:___________________

Total Population:____________________________
Date of Survey:_____________________________

DEMOGRAPHIC PROFILE

1. TOTAL POPULATION
Age Range Male Percetage Female Percentage Total
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65 and above
TOTAL

2. CIVIL STATUS
Civil Status Frequency Total
Child
Single
Married
Separated
Widow
Live-in
Total

3. RELIGION
Religion Frequency Total
Roman Catholic
Protestant
Iglesia ni Cristo
Total

4. OCCUPATION
Occupation Frequency Total
White Collar Job
Blue Collar Job
Unemployed
Total
 5. MONTHLY INCOME
Monthly Income Frequency Total
<1,000
1,001-5,000
5,001-10,000
10,001-15,000
15,001- 20,000
20,001- 25,000
25,001- 30,000
30,001 and above
TOTAL

6. EDUCATIONAL ATTAINMENT
Educational Attainment Status Frequency Total
Did not go to school
Elementary Level
Elementary Graduate
High School Level
High School Graduate
College Level
College Graduate
TOTAL
Under the Status column, write the following:
NFE-No Formal Education; PS- Presently Studying; SS- stopped studying

7. DIALECT
Dialect Frequency Total
Batangas
Tagalog
Ilocano
Sambal
Ilonggo
Waray
Etc
Total

ENVIRONMENTAL ASPECT:

1. HOUSING
Ownership Frequency Total
Owned
Rented
Rent-Free
Others
Total

Types of Housing Frequency Total

Concrete
Wood
Mixed
Makeshift
Total

Space Frequency Total

Congested
Non-congested
Total

Ventilation Frequency Total

Adequate
Inadequate
Total

FIRE AND SAFETY

Source Frequency Total
 Electricity
Kerosene
Other
Total

Cables/ Wires Frequency Total

Arranged
Octopus type
Total

Food Storage Frequency Total

Refrigerated
Covered/ not refrigerated
Exposed
Total

Water Source Frequency Total

Point Source
Communal Faucet
Waterworks System
Shared
Total

Garbage Disposal Frequency Total

Collected
Dumped
Burned
Waste Segregation
Total

Excreta Disposal Frequency Total

Pit Latrines
Pour Fluch Toilet
Flush Toilet
Balot System
Shared
Total

Food Storage Frequency Total

Refrigerated
Covered/ not refrigerated
Exposed
Total

Toilet Facility Ownership Frequency Total

Owned
Shared
Public
None
Total

Sewerage System Frequency Total

Open Drainage
Blind Drainage
None
Total

Condition of Drainage Frequency Total

Stagnant
Free-Flowing
None
Total

Presence of Breeding sites Frequency Total

of vectors
With
Without
Total

HEALTH ASPECT
1. HEALTH SEEKING BEHAVIOR
 Health Seeking Behavior Frequency Total
Hospital
Private Doctor
Health Center
Self Medication
Herbal Medicine
Others
Total

2. SOURCE OF HEALTH INFORMATION

SOURCE OF HEALTH Frequency Total
INFORMATION
Hospital
Health Center
Media
Others
Total

3. RESOURCES ALLOTED FOR HEALTH CENTER

Health Seeking Behavior Frequency Total
Health Insurance
Phil.Health
SSS/GSIS
None
Total

4. Medication Taken Frequency Total

During Illness
Prescribed
OTC
Herbal
Total

5. Recognized Leaders in Frequency Total

the Community
Brgy. Officials
Elders
NGO
Religious Leaders
others

Total

6. Community programs Frequency Total

in the community

Total

7. Community programs Frequency Total

in the community

Total

MATERNAL AND CHILD HEALTH

1. Family Planning
Utilization of Family Frequency Total
Planning
Acceptor
 Non- Acceptor
Total

Total

2. Family Planning Method

Family Planning MEthod Frequency Total
Natural
Rhythm
Cervical Mucus
Body Basal Temp.
Artificial
Condoms
IUD
Pills
Total
Permanent
Vasectomy
Tubal Ligation
Total
Note: Total Frequency should be the same as the total frequency of acceptors in table above

3. Infant Feeding Program

Infant Feeding Program Frequency Total
Breastfeeding
Formula Feeding
Mixed

Total

Formula Frequency Total

Condensed Milk
Evaporated Milk
Powedered Milk
Am
Total

4. Pre-natal Check-up
Check-up Frequency Total
With Pre-natal check-up
Withour pre-natal check up

total

Vaccination Frequency Total

With TT Vaccination
Without TT Vaccination

total
EXPANDED PROGRAM ON IMMUNIZATION

Vaccination Frequency Total

Has completed vaccination
incomplete
Fully Immunized
Total
*For 0-12 months only
*Note: The total Frequency should be equal to the total population of 0-12 months in the baranggay
 Non- Communicable Disease/ Di nakakahawang Sakit

Question No.1 Frequency Total

Meron
Wala
Total

Question No.2 Frequency Total

Wala
1
2
3
Atbp
Total

Question No.3 Frequency Total

Puso
Altapresyon
Sakit sa Puso
Baga
Hika
Emphysema
Bronchitis
Bronchiectasis
 Atbp
Atay
Cirrhosis
Atbp
Hormone
Diabetes Mellitus
Goiter
Isip
Stroke
Epilepsy
Parkinson
Pagiging Makakalimutin
Tiyan
Ulcer
Appendicitis
Balat
Galis-aso
Buni
An an
Pag-ihi
Sakit sa bato
atbp
atbp
Kanser
Total

Question No.5A Frequency Total

Pananakit ng Dibdib
BiglangPAgkahilo
Pananakit ng Batok
Palpitasyon
Atbp
Total

Question No.5B Frequency Total

Paminsan minsanoagkaranas ng
paghirap sa paghinga
Pag-ubo na may plema
Pag-ubo na walang plema
Atbp
total

Question No.5C Frequency Total

Paninilaw ng mata at balat
Pamamanas
Pagkakaroon ng rashes
Pananakit ng tiyan

Question No.5D Frequency Total

Pagkakaroon ng bukol sa leeg
Di gumagaling na sugat
Pamamanas
Parang tinutusok ng karayon ang
mga daliri
Maya’t mayang pagkagutom
Maya’t mayang pagkauhaw
atbp
total

Question No.5E Frequency Total

Pagkawala ng kakayahang magsalita
Pagkaparalisa ng isang bahagi o
buong katawan
Panghihina
Biglang pagkahilo at pagkawalang
malay tao
Matinding pananakit ng ulo
Pagkawala ng memorya
Panginginig ng katawan lalo na kugn
walang ginagawa
Pangingisay
Atbp
 total

Question No.5F Frequency Total

Pananakit ng tiyan kapag kumakain
Pananakit ng tiyan pagdi kumakain
Pagsusuka
atbp
total

Question No.5G Frequency Total

Pamumula ng balat
Pangangati
Pagkakaroon ng sugat
Tuyo at magaspang na balat
atbp
total

Question No.5H Frequency Total

Pananakit ng kanang bahagi ng
katawan
Kakaibang kulay sa ihi
Nahihirapang umihi
Atbp
total

Question No.5I Frequency Total

Panghihina
Pagbabago ng dalas ng pag ihi at
pagdumi
Pananakit ng apektadong katawan
Pagbabago ng itsura ng nunal
atbp
total

Question No.6 Frequency Total

Doktor
Kumadrona
Nars
Hilot
Albularyo
BHW
Atbp
total

Question No.7 Frequency Total

Halamang gamot
Pagpapausok (nebulization)
Gamot na nabibili sa botika
Pagpupunas ng maligamgam na
tubig
Pagpunas sng vicks
Atbp
total

Question No8 Frequency Total

Pagkain
Pananahon
Bisyo
Nausog o Nabati
Atbp
total

Communicable Disease/ Nakakahawang Sakit

Question No.1 Frequency Total

Meron
Wala
Total

Question No.2 Frequency Total

 Wala
1
2
3
4
Atbp
Total

Question No.3 Frequency Total

Tuberculosis
Diarrhea
Tigdas
Pneumonia
Malaria
Bulutong
Scabies
Hepatitis
Dengue
Rabies
Atbp
Total

Question No.5A Frequency Total

Pagkakaroon ng lagnat tuwing hapon
Pangangayayat
Panankit ng dibdib at likod
Pagkakaroon ng ubi mahigit isang
buwan
Mabilis na pagkahapo
Walang gana sa pagkain
Pagkakaroon ng dugo sa plema
Atbp
Total

Question No.5B Frequency Total

Ubo na may lagnat
Lagnat
Nahihirapang huminga
Panginginig
Pananakit ng likod at dibdib
Atbp
Total

Question No.5C Frequency Total

Panghihina
Lagnat
Pagsusuka
Sakit ng tiyan
Paninilaw
Atbp
Total

Question No.5D Frequency Total

Matubig na dumi
Lagnat
PAgsusuka
Pagkakaroon ng ubi mahigit isang
buwan
Matinding sakit ng ulo
Matinding pagpapawis
Panginginig
Atbp
 Total

Question No.5F Frequency Total

Lagnat na tumatagal ng 3-5 araw
Matinding sakit ng ulo
Pagsusuka
Paglaki ng tiyan
Panghihina
Pangangayayat
Atbp
Total

Question No.5G Frequency Total

Lagnat
Pangangati ng balat
Pagkakaroon ng pantal sa katawan
Total

Question No.5H Frequency Total

Lagnat
Pamumula ng balat
Pangangati ng katawan
Total

Question No.5I Frequency Total

Lagnat
Paninigas ng panga
Paglalaway
Takot sa tubig
Kombulsyon
Atbp
Total

Question No.5J Frequency Total

Pagtatae
Pagdumi ng may dugo
Pagsusuka
Panghihina
Paglaki ng tiyan
Pangangayayat
atbp
Total

Question No.5K Frequency Total

Pangangati
Sugat a dumadami
Pamumula ng balat
atbp
Total

Question No.6 Frequency Total

Doktor
Kumadrona
Nars
Hilot
Albularyo
BHW
Atbp
total

Question No.7 Frequency Total

Halamang gamot
Pagpapausok (nebulization)
Gamot na nabibili sa botika
Pagpupunas ng maligamgam na
tubig
Pagpunas sng vicks
 Atbp
total

Question No8 Frequency Total

Pagkain
Pananahon
Bisyo
Nausog o Nabati
Atbp
total

Prepared by Mrs. Marieta D. Lapuebla

Program Head

Csa 11/18/07