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Community Health Assessment Form

This document is a community health assessment form containing information about a family such as their address, income sources, housing conditions, access to healthcare services, nutrition, common illnesses, and health practices. It collects data on family members, socioeconomic status, home environment, available community resources, nutritional habits and disorders, health knowledge and behaviors. The form is used to evaluate a family's health needs and determine what health education topics would be most useful.

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Charise Ligores
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© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
3K views

Community Health Assessment Form

This document is a community health assessment form containing information about a family such as their address, income sources, housing conditions, access to healthcare services, nutrition, common illnesses, and health practices. It collects data on family members, socioeconomic status, home environment, available community resources, nutritional habits and disorders, health knowledge and behaviors. The form is used to evaluate a family's health needs and determine what health education topics would be most useful.

Uploaded by

Charise Ligores
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Community Health Assessment Form Respondent: Stage: Relation to Head (if not head of the Family): I.

Family Data A. Head of the Family: B. Name of Spouse C. Address D. Educational Attainment i. Husband ii. Wife E. Length of Residency: F. Ethnic Origin: G. Family ( ) Nuclear ( ) Extended H. Religion: I. Number of Children: J. Members of the Household NAME AGE SEX Age: Sex:

Age: Age:

EDUCATION

OCCUPATION

II. Socio-Economic Data A. Source of Income Occupation Husband: Wife: Garbage Collector; part of Recyclers Association Employed ( ) Unemployed ( ) Self-Employed ( ) Monthly Income Below P2000 ( ) P2,000-P5,000 P5,001 P8, 000 ( ) more than P8,000 B. Family expenditures 1. Food Below P50 ( ) More than P70 ( ) 2. Clothing: number of times buying Once ( ) Thrice ( ) 3. Housing Water ( ) Telephone ( ) 4. Schooling Public ( )

( ) ( )

P50 75

( )

Twice

( )

Electricity

( )

Private

( )
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5. Others: III. Housing and Environmental Conditions A. Home Type Concrete Mixed Others: Ventilation: Poor Lighting Adequate Surroundings Clean

( ) ( )

Wood Makeshift

( ) ( )

( ) ( ) ( )

Good Inadequate Dirty

( ) ( ) ( )

B. Source of Water Supply Artesian Well NAWASA ( )

( )

Deep well Others:

( )

C. Storage of Drinking Water Refrigerated Uncovered ( ) Containers used: Plastic Bottles D. Toilet Facilities Sanitary: Flush Shared Others: Unsanitary: Ballot System E. Garbage Disposal Collection Burying Garbage Cans F. Food Storage Covered Refrigerated G. Presence of Animals Dogs Pigs

( )

Covered

( )

( ) ( )

Clay Jars Others:

( )

( ) ( )

Pit privy Owned

( ) ( )

( )

Others:

( ) ( ) ( )

Burning Open Dumping Others:

( ) ( )

( ) ( )

Uncovered

( )

( ) ( )

Cats Others:

( )

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H. Backyard Gardening Vegetables Fruit-bearing IV. Community Resources A. Health and Other Facilities Health Center School Church

( ) ( )

Herbal

( )

( ) ( ) ( )

Barangay Hall Park Market

( ) ( ) ( )

B. Indigenous Health Workers Trained Hilot ( ) Herbularyo ( ) Others: C. Sources of Health Funds Government NGOs/Pos V. Nutrition A. Food Preferences Fish Meat

BHW Untrained Hilot

( ) ( )

( ) ( )

Private Others:

( )

( ) ( )

Fruits/vegetables ( ) mixed

( )

B. Common Fare Rice and egg Rice and noodles

( ) ( )

rice and sardines ( ) others:

C. Presence of Nutritional Disorder Goiter Enlargement of neck ( ) Hoarseness ( ) Anemia Pallor ( ) Body Weakness ( ) Vitamin A deficiency Night blindness ( ) Others:

dysphagia Others: Easy fatigability

( )

( )

Pilaksamata

( )

VI. Knowledge, Attitude and Practice A. Do you utilize the health center? Yes ( ) If no, why? B. Reason Illness Family Planning Dental

No

( )

( ) ( ) ( )

Prenatal Postnatal Nutrition

( ) ( ) ( )
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Immunization

( )

C. First person consulted in times of illness M.D. ( ) Nurse Midwife ( ) Hilot Herbularyo ( ) BHW Others: D. Usual Illness in the Family

( ) ( ) ( )

What do you do for this condition? Self Medication ( ) Consultation Hospital ( ) Private Clinics Nursing ( ) Others: E. Other Diseases TB ( ) Leprosy Skin diseases ( ) Hepatitis ( ) Others: heart disease and cancer F. Do you submit your children (0-12 months) for immunization? Name of Child Birthday BCG DPT OPV

( ) ( )

( )

AM

G. Do you practice family planning? Yes ( ) No Method: If no, why? H. Method of Infant Feeding Breast Mixed

( )

( ) ( )

Bottle

( )

I. Subjects you want to learn in health education: no specific Drug abuse ( ) Nutrition ( ) Family Planning ( ) Herbal Plants First Aid Measures ( ) Others:

( )

Interviewed by: Date: Time:


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