Comprehensive Social Health Survey
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ScribdTranslationsComprehensive Social Health Survey
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ScribdTranslationsSOCIAL HEALTH SURVEY
FILL IN WITH CLEAR UPPERCASE PRINT
Location: Match: Date: / /
Block No: Block No: Housing No:
Street: No. or Ref:
REFERENCE CAPS:
Interview Conducted YES NOREASON: 1 Absent Residents
2 Unemployed
3 He refuses to answer
I. HOUSING AND FAMILY
Number of people living in the house
Home current Sewers, public service Home Collection
2 Public tap 2 Septic tank, well 2 Burial or burning
3 Tank or cistern 3 Toilet with D.S.E 3 Trash pit
4 Pump or mill 4 Toilet without D.S.E 4 neighborhood containers
5 Cistern 5 Open Sky 5 Without treatment
6 Well or bucket
7 Reservoir pond 1 Mosaics or tiles 1 Bricks
8 River, irrigation ditch
2 Cement 2 Adobe
3 Earth 3 Wood
Electrical installation: 4 Stone
4 Others:
Gas installation: 5 Block
Farm Garden 6 Quincho, tarpaulins
Rooms Birds Fruits 7 Cardboard, plastic
Kitchen 2 Goats 2 Vegetables 8 Others:
Bathroom 3 Pigs 3 Tubers.
4 Sheep 4 Grains 1 Loza
Living room dining
5 Cows 5 Others: 2 Fiber Cement
Patio 3 screws
6 Others:
4 Quincho
5 Cardboard, plastic
How often do you clean the house deeply? 6 Others:
Every day Note: Who is in charge of the
2 or more times a week cleaning?
3 times a week
4 Others:
Meeting schedules of the complex family
1 Breakfast
2 Lunch
3 Snack OBSERVATION
4 Dinner
5 Others:
Does the family engage in recreational activities?
YES NO Which OBSERVATION
Where do the children play?
1 Patio
Inside the house
3 Plaza OBSERVATION
4 Street
5 Others:
Do seniors over 65 engage in any activities?
YES NO Which OBSERVATION
Who is in charge of children, the elderly, and the disabled?
II. SOCIAL HEALTH PROBLEMS
Child under 1 year old
Child from 1 to 6 years old
Senior adult over 70
Under 17 years old who does not attend school
Over 21 years old who is not working and is looking for a job
(Prudent observation, mark with a cross)
Violence: Physical Psychological OBSERVATION
Child abuse
Sexual abuse of minors
Adicciones: Drogas (edad) Alcohol (edad)
DISABILITY
Is there any disabled member in the household?
IF NO OBS:
Birth Acquired
Motor Mental Visual Auditory
Do you have a disability certificate?
YES NO OBS:
PREGNANCY
Age Month of gestation It is controlled: YES NO
Medical part. Hospital Health center Private clinic
Has any family member had or has fertility problems (unable to have children)?
IF NO OBS:
III. HEALTHCARE ATTENTION
Generally, when someone gets sick, they go to:
Health center Hospital Other:
If they do not attend the health center, reasons:
He/She does not know him/her, does not know where he/she is.
It doesn't give him/her confidence. Frequency of medical consultations
It takes a long time to be attended to. once a month
He/She is not used to going to the Health Center. Every 6 months
5 It is far from him 3 once a year
6 Other Only when required
How often do you brush your teeth?
None
2 times a day
3 to 4 times a day
Why do you go to the dentist?
Control Urgency
What contraceptive methods do you use?
1 Condom
2 Pills
3 IUD
4 Injection
5 Others
6 None
IV. WORK
{"familyMembers":"Which family members work?","hoursPerDay":"How many hours per day?","formalOrInformal":"Formal or informal?"}
1 (less than 6) 1 (Formal)
2 (more than 6) 2 (Informal)
3 (more than 8)
Father
Mother
Children
Grandparents
Others
Do children under 16 years old perform any activities for others?
IF NO Which OBSERVATION
V. EATING HABITS
Do you have the four daily meals?
1 Breakfast
2 Lunch
3 Snack
4 Dinner
What food do you consume most frequently?
1 Meat
2 Vegetables
3 Fruits
4 Carbohydrates
5 Dairy
Who is in charge of preparing the food?
1 Father
2 Mother
3 Grandparents
4 Children
5 Others
Does anyone in the family drink alcohol?
IF NOT OBS:
Is there anyone in the family who smokes?
IF NO How many members: OBS:
How do you describe your health situation?
What are the issues that cause the most concern in your family?
