UNIVERSITY OF PERPETUAL HELP SYSTEM

Sto. Nio, Bian, Laguna

COLLEGE OF NURSING
COMMUNITY DIAGNOSIS
Barangay:____________________________________ Purok: _______________
Family Name: _______________________________
Family Size:__________________________________

Total Population: _________________________

Length of Residency: ______________________
Place of Origin: ___________________________

I. Demographic Variables
Name

Religion

Age

Sex

Civil Status

Educational Attainment

1
2
3
4
5
6
7
8
9
10

Type of Family Structure:

Based on Internal Organization and Membership

[ ] Nuclear
[ ] Extended

Based on Place of Resident:

[ ] Patrilocal
[ ] Matrilocal
[ ] Bilocal
[ ] Neolocal
[ ] Avunculocal

Based on Decent:
[ ] Patrilineal
[ ] Matrilineal
[ ] Bilateral

Based on Authority
[ ] Patriarchal
[ ] Egalitarian

II. Socio-Economic and Cultural Variables

A. Social Indicators

[ ] Matriarchal
[ ] Matricentric

1. Means of Communication
[ ] Landline
[ ] Mobile Phone
[ ] E-mail
[ ] Postal Mail
[ ] Others: _________________

2. Modes of Transportation
[ ] Tricycle
[ ] Jeepney
[ ] Pedicab
[ ] Bus
[ ] Other: _______________

3. Health Hazards (Housing Conditions)

[ ] Congestion
[ ] Exposure to Chemicals
[ ] Fire Hazard
[ ] Electric Wires
[ ] Others: ________________

B. Economic Indicators
Name

Employment
Status

Occupation

Place of Work

Income
Salary

Wage

1
2
3
4
5
1. Total Monthly Income
[ ] No Income [ ] 1,000-2,999
[ ] 1-999
[ ] 3,000-4,999
C. Environmental Indicators
1. Type of Neighborhood
[ ] Congested
[ ] Squatter

[ ] 5,000-6,999
[ ] 7,000 and above

2. Industry Present in the Community:

___________________________
No: ________________________

2. Lot Ownership
[ ] Owned
[ ] Rented
[ ] Squatting

3. House Ownership
[ ] Owned
[ ] Rented
[ ] Free

4. Type of House
[ ] Concrete
[ ] Mixed w/ Cement
[ ] Makeshift
[ ] Mixed w/ Wood
[ ] Other: ______________

5. Ventilation
[ ] With
How: __________
[ ] Without

6. Lighting Facilities
[ ] W/ Electricity
[ ] W/O Electricity
How: ____________

7. Cooking Environment
[ ] Backyard
[ ] Sidewalk
[ ] Other:______________

8. Cooking Facility
[ ] LPG
[ ] Charchoal
[ ] Kalan de Bomba [ ] Wood
[ ] Other: ____________

9. Water Source
[ ] MWSS
[ ] Deep Well
[ ] Artesian
Ownership
[ ] Owned
[ ] Shared Distance: _____

10. Type of Toilet (Excreta Disposal)

[ ] Flush Type
[ ] Pit Privy
[ ] Pail System
[ ] Overhang Latrine
[ ] Other: ______________
Ownership
[ ] Owned
[ ] Shared
Distance: ______

11. Garbage Disposal

[ ] Collected
[ ] Burying
[ ] Open Dumping
[ ] Burning
[ ] Other: _______________

12. Drainage System

[ ] Open
[ ] Closed
[ ] None

D. Cultural Factors
1. Race:
__________________________
2. Ethnicity:

4. Birth Attendant
[ ] Hilot
[ ] Midwife
[ ] MD
[ ] No Child

5. Herbal Medicine
[ ] Taheebo
[ ] Sambong
[ ] Lagundi
[ ] Oregano

6. Family Planning
[ ] Pills
[ ] Condom
[ ] Surgery [ ] Withdrawal

__________________________
3. Language:
__________________________

[ ] Other: _____________

[ ] Bayabas

[ ] Other: __________

[ ] None

[ ] Other: __________

Other Health Practices: _________________________________________________________________________________________________

_________________________________________________________________________________________________
III. Heal and Illness Patterns
1. Immunization (under 5 yrs old)
Name
1
2
3
4
5
2. Present Illness
Name

Age

BCG

DPT

OPV

Measles

Weight

Height

Age

Date

Disease Suffered

Medical Attendance
With
Without

Treatment

Age

Date

Disease Suffered

Medical Attendance
With
Without

Treatment

Age

Date

Disease Suffered

Medical Attendance
With
Without

Treatment

1
2
3
4
5
3. Past Illness (past 6 months)
Name
1
2
3
4
5
4. Death within 5 years
Name
1
2
3
4
5
IV. Health Resource
A. Manpower Resources
1. Health Resources
[ ] Health Center
[ ] Private Clinic
No: ___

2. Health Workers in Health Center

[ ] Physician
No: _____
[ ] Nurse
No: _____

3. Health Workers in Private Clinic

[ ] Physician
No: _____
[ ] Nurse
No: _____

4. Health Workers in Hospital

[ ] Physician
No: _____
[ ] Nurse
No: _____

[ ] Hospital
No: ___
[ ] Other: _______ No: ___

[ ] Midwife
[ ] BHW

No: _____
No: _____

[ ] Midwife

No: _____

Capacity: __________

[ ] Midwife

No: _____

Capacity: __________

Present Health Center Programs: : _______________________________________________________________________________________

__________________________________________________________________________________________
B. Material Resources
1.Community Resources
[ ] Barangay Hall
[ ] Health Center
[ ] Market
[ ] School
[ ] Church
[ ] Park
3. Familys Source of Health Fund
[ ] Income
[ ] Govt Assistance
Org: ___________
Amt: ___________
[ ] Private Health Agency [ ] None
[ ] Other: _________________

2. Amount of Money Spent on Health Maintenance Monthly

[ ] None
[ ] 1,000-2,999
[ ] 5,000-6,999
[ ] 1-999
[ ] 3,000-4,999
[ ] 7,000 and above
4. Categories of Health Services Available
[ ] General Check-up
[ ] Prenatal Check- up
[ ] Immunization
[ ] Free Medicine
[ ] Other: ________________

V. Political/Leadership Patters
1. Barangay Officials
Barangay Captain: _________________________
Kagawad: ________________________________
Tanod: __________________________________
SK: _____________________________________
Others: __________: _____________________________
__________: _____________________________
__________: _____________________________
2.Relationship with the Barangay Officials
[ ] Good
[ ] Fair
[ ] Poor
Good: No Conflicts
Fair: Some Conflicts
Poor: Many Conflicts
3. Cause of social conflict/unification: __________________________________________________________
4. Practices/ Approach to settle conflict or promote bonding: ________________________________________

Interviewee: ____________________________________
Interviewer: ____________________________________
Date: _________________
Section/Group: _________