Scribd
Upload
74 views

Initial Data Base Questionnaire

This document contains a form for collecting information about a family, including their demographic details, socioeconomic status, housing/environmental conditions, and health status. Sections include basic identifying information, a table of family members, income/expenditure, nutrition, housing/sanitation, and a health assessment of each member. The purpose is to gather a comprehensive set of data on a family to understand their needs and living situation.

Uploaded by

MariahnaSadjaluddin
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
74 views

Initial Data Base Questionnaire

This document contains a form for collecting information about a family, including their demographic details, socioeconomic status, housing/environmental conditions, and health status. Sections include basic identifying information, a table of family members, income/expenditure, nutrition, housing/sanitation, and a health assessment of each member. The purpose is to gather a comprehensive set of data on a family to understand their needs and living situation.

Uploaded by

MariahnaSadjaluddin
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 3

Client’s Name: Occupation:

Age: Educational attainment:


Sex: Relationship to the head of the family:
I. Initial Data Base of the Family

Name Relation Sex Age Civil Position in the Place of Residence


to Head Status family

1.)

2.)

3.)

4.)

5.)

6.)

Length of residency:
Type of family structure:
No. of children:
Dominant family members in terms of decision making:
II. Socio economic Data

Members of the Occupation Income Place Educational Ethnic Religion


family of Attainment background
work

Joined monthly income:


Below 2000php ( ) 3000php-5000php ( ) 5001php-8000php ( ) more than 8000php ( )

B. Basic Expenditures
1. Food daily
Below 50php ( ) 50php-75php ( ) More than 80php ( )
2. Clothing no. of times of buying in a year
Once ( ) Twice ( ) Thrice ( ) more than ( )
3. Housing
Water ( ) Electricity ( ) Telephone ( )
4. Schooling
Public ( ) Private ( )
5. Others:
C. Nutrition

1. Food preference
Fish ( ) Fruit/Vegetable ( ) Meat ( )
2. Common pair
Rice and eggs ( ) Rice and noodles ( ) Rice and sardines ( ) Others:

III. Housing and environmental condition


A. House
1. Type of housing
Concrete ( ) Wood ( ) Mixed ( ) Makeshift ( )
Others:
2. Ownership
Owned ( ) Rented ( ) Rent-free ( ) Others:
3. No. of rooms for sleeping:

4. Ventilation:
Poor ( ) Good ( )
5. Lighting facilities
Electricity ( ) Kerosene ( ) Others:
6. General Sorroundings
Clean ( ) Dirty ( )
B. Source of water supply
Artesian well ( ) Deep well ( ) NAWASA ( ) Water district ( )
C. Storage of drinking water
Refrigerated ( ) Covered ( ) Uncovered ( )
D. Kitchen
Electric stove ( ) Gas stove ( ) Charcoal/Firewood ( )
E. Drainage
Open ( ) Blind ( ) None ( )
Sanitary observations:
F. Containers used: Plastic ( ) Jars ( ) Others:
G. Toilet facilities:
Owned ( ) Shared ( ) Communal ( )
Sanitary: Flush ( ) Close privy ( ) Water sealed ( )
Unsanitary: Ballot system ( ) Antipolo ( ) Cat hole ( ) Others:
H. Waste Disposal:
Hog feeding ( ) Collected ( ) Composting ( ) Open dumping ( ) Burned ( )
Burial inpit ( ) Garbage cans ( ) Others:

I. Drainage Systems(Residential Drainage System, Surface Drainage, Subsurface Drainage, Slope Drainage)
____________________________________________
J. Food Storage
Covered ( ) Refrigerated ( ) Uncovered ( )
K. Presence of Animals
Dogs ( ) Cats ( ) Pigs ( ) Others:
L. Backyard Gardening
Vegetables ( ) Herbal ( ) Fruit Bearing ( ) Others:
M. Community Observations
i. Sanitary Conditions:
ii. House: Slum ( ) Congested ( ) Squatters ( )
iii. Presence of breeding sites for vectors:
iv. Health Facilities:
v. Recreational Facilities:
vi. Distance of the house to nearest health care facility:
IV. Health Status of each family member
1. Medical History, belief medical practices:
S:

O:

2. Nutritional assessment
a. Anthropometrics measurement: weight, height, MUAC
S:

O:

b. Dietary history of food intake


S:

O:

c. Eating, feeding habits


S:

O:

3. Developmental assessment of infants toddlers and pre-schoolers

S:

O:

4. Physical assessment wether indicated by diagnosis


S:

O:
5. Result of laboratory/diagnostic procedures supportive by physical assessment findings
S:

O:

Values and Practices for health promotion

1. Immunization status of family members

2. Use of preventive health services

3. Adequacy of rest and sleep, exercise, relaxation activities, stress management practices

You might also like