COMMUNITY HEALTH SURVEY TOOL I. Household Members Surname Given Name Middle Initial Age Sex Family Position (ordinal) Relation to the Head Birth Date Civil Status Highest Educational Attainment Occupation and Daily/ Monthly Salary Immunization Status Literacy Status Remarks 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Put * after the surname of deceased individual. Wri te the cause and place of death under the remarks column. In addition, note down in the same column any health abnormalities of the above individuals indicating in terms of prenatal, postpartum, mentally retarded, morbid case (specify present illness), malnourished, and overweight. Indicate the place of birth for neonates. Mark (x) if not immunized, C for complete and (?) if not known. Place O.S.if out of school then write the reason under the column remarks. Use the term employed, retired, and unemployed for their occupational status. Indicate the literacy status whether literate (can read and write) or illiterate. II. Length of Residency III. Religion/Sect ( ) Roman Catholic ( ) Mormon ( ) Seventh Day Adventist ( ) Others (specify): _________ ( ) Born Again Christian ( ) SAKSI ( ) Islam IV. Place of Origin ( ) Region I ( ) Region III ( ) Region V ( ) Region VII ( ) Region IX ( ) Region XI ( ) CAR ( ) Region II ( ) Region IV ( ) Region VI ( ) Region VIII ( ) Region X ( ) Region XII ( ) CARAGA ( ) ARMM ( ) Abroad (specify): Specify the province: ___________
