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Chn Assessment Form

The Community Health Assessment Form collects detailed information about a family's demographics, socio-economic status, housing conditions, community resources, nutrition, and health practices. It includes sections for family data, income sources, expenditures, housing conditions, health facilities, and knowledge regarding health services. The form is designed to gather essential data for assessing community health needs and resources.

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littlebooknerd2
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9 views

Chn Assessment Form

The Community Health Assessment Form collects detailed information about a family's demographics, socio-economic status, housing conditions, community resources, nutrition, and health practices. It includes sections for family data, income sources, expenditures, housing conditions, health facilities, and knowledge regarding health services. The form is designed to gather essential data for assessing community health needs and resources.

Uploaded by

littlebooknerd2
Copyright
© © All Rights Reserved
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: ___________________________ 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: _________

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