COMMUNITY HEALTH ASSESSMENT FORM
Respondent: ___________________________ Age: ________
Relation to Head: ______________________ Sex: ________
I. Family Data
A. Head of the Family: _______________________ Age: _______
B. Name of Spouse: _________________________ Age: _______
C. Address: ___________________________ Tel. No. __________
D.Educational Attainment: _________________________
i. Husband: _______________________________
ii. Wife: ___________________________________
E. Length of Residency: _____________________________
F. Ethnic Origin: ___________________________________
G.Family
i. Nuclear ( ) Extended ( )
H.Religion: _______________________
I. No. Of Children: _________________
J. Members of the Household: __________
NAME AGE SEX STATUS EDUCATION OCCUPATION
II. Socio Economic Data
A. Source of Income
Occupation:
Husband: _____________________________
Wife: _________________________________
Employed ( ) Unemployed (
)
Self-employed ( )
Monthly Income:
Below 2,000 ( ) 2,000-5,000
( )
More than 70 ( )
B. Family Expenditures
1. Food
Below 50 ( ) 50 – 75 (
)
More than 75 ( )
2. Clothing: number of times of buying
Once a year ( ) Twice (
)
Thrice ( )
3. Housing
Water ( ) Electricity
( )
Telephone ( )
4. Schooling
Public ( ) Private
( )
III. Housing and Environmental Condition
A. Home
Type
Concrete ( ) Mixed (
)
Wood ( ) Makeshift (
)
Ventilation
Poor ( ) Good
( )
Lighting
Adequate ( ) Inadequate ( )
Surroundings
Clean ( ) Dirty
( )
B. Source of Water Supply
Artesian Well ( ) Deep Well (
)
Nawasa ( )
C. Storage of Drinking Water
Refrigerated ( ) Covered
( )
Uncovered ( )
D.Toilet Facilities
Sanitary:
Flush ( ) Pit Privy
( )
Unsanitary:
Ballot System ( )
E. Garbage Disposal
Collection ( ) Burning
( )
Burying ( ) Open
Dumping ( )
Garbage Can ( )
F. Food Storage
Covered ( ) Uncovered
( )
Refrigerated ( )
G.Presence of Animals
Dogs ( ) Cats
( )
Pigs ( )
H.Backyard Gardening
Vegetable ( ) Herbal
( )
Fruit bearing ( )
IV. Community Resources
I. Health and Other Facilities
Health Center ( ) Barangay Hall
( )
School ( ) Church
( )
Park ( ) Market
( )
J. Indigenous Health Workers
Trained Hilot ( ) BHW
( )
Herbularyo ( ) Untrained
Hilot ( )
K. Sources of Health Funds
Government ( ) Private
( )
NGO’S/PO’S ( )
V. Nutrition
A. Food Preferences
Fish ( )
Fruits/Vegetables ( )
Meat ( ) Mixed
( )
B. Common Fare
Rice & Egg ( ) Rice &
Sardines ( )
Rice & Noodles ( )
VI. Knowledge, Attitude and Practice
A. Do you utilize the health center? Yes ( )
No ( )
If no, why?
B. Reason:
Illness ( ) Prenatal
( )
Family Planning ( ) Postnatal
( )
Dental ( )
Nutrition ( )
C. First person consulted in times of illness:
M.D. ( ) Nurse
( )
Midwife ( ) “Hilot”
( )
“Herbularyo” ( ) BHW
( )
D.Usual illness in the family
_____________________________ _____________________________
_____________________________ _____________________________
_____________________________ _____________________________
What do you do for this condition?
Self-medication ( )
Consultation ( )
Hospital ( ) Private
( )
Nursing ( )
E. Do you submit your children ( 0-12 months ) for immunization?
NAME OF CHILD BIRTHDAY IMMUNIZATION
BCG DPT OPV M
F. Do you practice family planning? Yes ( )
No ( )
Method:
If no, why?
G.Method of Infant Feeding:
Breast ( ) Bottle
( )
Mixed ( )
H.Subjects you want to learn in health education:
Drugs ( ) Nutrition
( )
Family Planning ( ) Herbal Plants (
)
First Aid Measure ( )
Interviewed by: ___________________________ Date: ___________
Time: _________
