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ST. PAUL’S HOSPITAL OF ILOILO, INC.
DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE
SURVEY QUESTIONNAIRE for BRGY. SAN RAFAEL, MANDURRIAO, ILOILO CITY
Questionnaire No: Household No: Date: Good morning/afternoon! We are clinical clerks / post-graduate interns from Central Philippine University College of Medicine/St. Paul’s Hospital of Iloilo, Inc Department of Family and Community Medicine. Our group has chosen Barangay San Rafael, Mandurriao, Iloilo City as its adopted barangay to conduct a survey. The purpose of this survey instrument is to get baseline data for our Community Analysis Project as a requirement for our Family and Community Medicine subject. It is expected that this survey will take about 15 minutes to complete.We are assuring you that whatever information you have provided to us will be kept confidential and will be used entirely for our study. If you agree to be part of this survey, please indicate your name and affix your signature above it. Thank you! Name and Signature (Maayong aga/hapon, ma’am/sir, kami gali ang clinical clerks / postgraduate interns halin sa Central Philippine University / St. Paul’s Hospital Iloilo, Inc. Department of Family and Community Medicine. Ang amon grupo ginpiili ang Barangay San Rafael, Mandurriao, Iloilo City bilang adopted barangay kung sa diin magahiwat kami sang isa ka survey. Ang survey nga ini pagagamiton ang mga makalap nga datos para sa amon pagahimuon nga Community Analysis Project bilang isa ka requirement sa Family and Community Medicine nga subject. Ang ini nga survey gina expecter nga makumpleto sa sulod sang kinse ka minutos. Ginasigurado namun nga ang mga impormasyon nga amon nga makalap diri kay kompidensyal and pagagamiton lamang para sa amon study. Kung ikaw naga uyon nga mangin parte sini nga survey, pwede mo bala masulat imo ngalan kag mairmahan sa linya diri. Salamat gid!) Interviewer: Interviewee:
BLOCK I. SOCIO-DEMOGRAPHIC INFORMATION
FAMILY ASSESSMENT
Name: Age: Sex: Civil Status: Height: Weight: BP: Birth Date: Permanent Address: Religion: Current Address: Educational Attainment: Occupation: COVID-19 Vaccines (Dates): Booster (Date): Total Monthly Income: Below ₱ 5,000 ₱ 5,001 – ₱ 10,000 ₱ 10,001 – ₱ 15,000 Above ₱ 15, Sources: Salary Business Landholdings Allotment Pension Others, specify: Members of the Family: Name Family Role Age Sex (^) Civil Status Educational Attainment Occupation Ht. Wt. BP COVID- Vaccine Booster *Note: For Fully Vaccinated – A; Partially Vaccinated – B; Unvaccinated - C *For the Booster - a check ( ✔ ) is written if he/she was given a booster while put an ( x) if no booster at all.
4. Type of building materials used for the house (Mga materyales nga gingamit pagpatindog sang balay) Light Materials (bamboo/kawayan, nipa/lukay, wood/kahoy) Concrete material (Cement/Semento, Steel, etc) Mixed Others (Specify) 5. Style of the house (Estilo sang balay) Studio Type One storey Two storey Others, specify: 6. Number of Rooms (Pila ka kwarto) one ( isa) two (duha) Others, specify: 7. Distance to the neighboring house (Distansya sang balay sa kaingod balay) Less than 1 meter 7-10 meters 1-3 meters 11-20 meters 4-6 meters More than 20 meters 8. Source of light (Suga nga ginagamit) - [Check all that apply] Electricity( elektrisidad) Gasul Generator Baterya sang salakyan Solar Kandila Oil lamp( mitsa, lampara, kinki) Others, specify: 9. Water Source (Tubig nga ginagamit): * use code a. For drinking / Ilimnon : b. For general purposes (Panghugas/Panglaba ): I. Deep well / water pump IV. Stream ( suba) II. NAWASA V. Rainwater ( Ulan) III. Purified Drinking Water VI. Others, specify: 9.1. Method of preparing for a clean drinking water (Pamaagi sang pagpreparar sang tubig nga ilimnon) Boiling ( pabukal) N/A (source of drinking water is from refilling station) Others, specify: 9.2 Distance of water source to the septic tank (Pila ka metro ang antad sang bubon/bomba sa septic tank?) 1-3 meters 10-12 meters 4-6 meters 13 meters or more 7-9 meters 9.3. Owner of the water source (Sin-o ang tag–iya sang ginakuhaan sang tubig?) a. For drinking (Ilimnon) : b. For general purposes (panghugas/panglaba) : I. Owner ( Tagbalay) V. Buy ( Ginabakal) II. Neighbor ( Kaingod) VI. Others, specify: III. Communal ( Mga Pumuluyo) 10. Where does the water drain after use? (Diin nagadiretso ang nagamit nga tubig?) - [Check all that apply] Pipes ( Tubo) Pit without cover (Buho, wala tabon) Stream (Suba) Sea (Baybay) Canal ( Kanal ) Field (Talamnan) Under the house (Idalom sang balay) Open area Pit with cover (Buho, may tabon) Others, specify: 11. Owns a comfort room? (May kasilyas nga ginapanag-iyahan?) Yes ( Huo) No ( Wala) If yes, what type? ( Kung huo, ano ang klase sang kasilyas?) Antipolo, covered Automatic flush Antipolo, not covered Others, specify: Water-sealed If none, what is the system used? (Kung wala, ano ang sistema nagamit?) Pit dry, covered Suba Pit dry, not covered Baybay “Balot / putos” system Punong Higad-higad Others, specify If “balot” system, where is it thrown off? (Kung “balot” system, diin ginahaboy ang higko?) Suba Higad-higad Baybay Basurahan Punong Others, specify: 12. Methods of waste disposal ( Paagi sang paghaboy sang basura) - [Check all that apply] Buried ( Ginalubong) Burning ( Ginasunog) Thrown at a pit ( Ginahaboy sa buho) Thrown anywhere ( Ginahaboy bisan diin lang) Taken by the garbage truck ( Ginakuha sang garbage truck) Others, specify:
BLOCK IV: SOCIO-CULTURAL
Is waste segregation being practiced at home? ( Gina ubra bala sa panimalay ang pagseparar sang basura sa madunot, indi madunot, ukon marecycle?) Yes No
13. Items used in cooking ( Ginagamit sa pagluto:) - [Check all that apply] Kahoy Labhang Uling Tubo ukon bagaso LPG Gas Elektrisidad Others, specify: Butane 14. How many times does the family eat in a day? ( Pila ka beses magkaon sa isa ka adlaw?) - [it should be a Full Meal] Isa Tatlo Duha Others, specify: 15. Usual viand ( Masami nga ginasud-an) - [Check all that apply] Isda Karne Baboy Seafoods Uga Manok Utan Others, specify: 16. Utensils for eating (Ginagamit kon magkaon) Kutsara kag tinidor Both Kamot Others, specify: 17. Storage for leftovers (Ginataguan sang pagkaon) - [Check all that apply] Basket Kaldero Refrigerator Ginatakpan Aparador Others, specify: 18. Pets in the house (May kasapatan sa balay?) Yes (Huo) None (Wala) A. Domesticated animals/ Pets ( Anta nga kasapatan) Dog ( Ido) Others, specify: Cat ( Kuring) B. Were animals immunized? ( Nakapa bakuna ang kasapatan?) Yes ( Huo) No ( Wala) C. Raised/Livestock animals ( Ginasagud nga kasapatan) Yes (( Huo )) None (( Wala)) D. If yes, what animals? ( Kung huo, ano nga mga kasapatan?) Manok Karabaw Baboy Pato Baka Ganza Kanding Others, specify: 19. Plants in the area (Mga tanom nga ara sa palibot sang balay?) - [Check all that apply] Ulutanon Herbal Bulak Others, specify: 1. Are you a member of any civic organization? (Miyembro ka bala sang isa ka organisasyon?) Yes, write the name of the organization (Kung huo, isulat ang ngalan sang organisasyon) No (( Indi)) Are other family members a part of civic organization? (May iba bala nga miyembro sang pamilya ang parte sang isa ka organisasyon?) Yes ( ( Huo) ) No ( ( Indi)) If yes, fill out table: Name Organization Position, if any:
- What is your usual source of current information? ( Ano ang mga bagay nga ginukuhaan niyo sang balita?) - [Check all that apply] TV Internet Radio Neighbors Newspaper Others, specify:
- What is your usual means of relaxation? (Ano ang mga bagay nga gaparelax/ gapatawhay sa inyo?) - [Check all that apply] Sports Gambling ( Sugal ) TV/movies Sleeping Computer Others, specify:
The succeeding questions is to be asked if there are pregnant women or postpartum women (up to 6 weeks post delivery) staying currently at the said household. ( Ang mga masunod nga pamangkot kay para lamang sa mga panimalay nga may ara gabusong ukon bag-ong bata dapat nasulod 6 ka semana panubo ang inadlaw halin sa ti-un sang pagbata) BLOCK VII : MATERNAL AND CHILD HEALTH Brgy. Officials Others, specify: Police station
2. Accessibility to health care facilities in case of emergency (may malapit bala nga Health care facility sa ti-un sang emerhensiya?) Yes ( Oo) None ( Wala) If yes ( huo ) Mode of transport (pamaagi para kakadto) Walking Tricycle Bus Others, specify: Time it takes going from house to nearest health care facility (pila ka minutos halin sa balay pakadto sa health facility?) <5 minutes 6-15 minutes 15-30 minutes >30 minutes 3. Accessibility to schools (may malapit nga eskwelahan?) Yes No Type of School: Public Private Mode of Learning Online , if yes, how many are attending online (pila ang ga online?) Modular , if yes, how many are doing modules? (pila ang ga module?) Mixed , if yes, how many are in a mixed learning? (pila ang ga mixed learning?) Limited Face-to-Face(F2F) , if yes, how many are in a F2F learning? (pila ang ga F2F classes?) 4. Accessibility to Church (may malapit nga Simbahan?) Yes No 1. Is there a pregnant / postpartum woman currently staying in the house (May ara bala nagbata / nagabusong sa inyo nga balay?) Yes ( Huo ) No (Wala) If yes, indicate name (Kon Huo, sin-o ) , Age of gestation (Pila ka bulan) , Number of pregnancy (Ikapila nga pagbusong) 2. Has a prenatal check -up ( Naga pa prenatal?) Yes ( Huo) No ( Wala) If yes, what is the age of gestation during the first prenatal visit ( kun huo, pila ka weeks ang imo pagbusong sang una nga pag prenatal ) How many total prenatal visits (Kon Huo, pila ka beses nakapa prenatal ) 2.a. Where is prenatal check-up done (Sa diin masami nagapa prenatal?) A. Brgy. Health Center D. Private Clinic B. Municipal Health Center E. Hilot C. Hospital F. Others, specify: If none, what is the reason? ( Kon Wala, ano ang rason) a. Financial b. Distance to health facility c. Unwanted pregnancy d. Others, Specify: For Questions 1- Name Age of gestation Number of Pregnancy (OB score) Prenatal(yes or no), if yes, how many weeks during the first prenatal Total Number of prenatal visits Where is it done? If no, reason 3. Had a dental check-up at the time of pregnancy (Naka pakunsulta sa dentista sa tion sang pagbusong?) Yes , how many times (Huo, pila ka beses): Wala 4. Underwent laboratory tests during pregnancy (Nakapa eksamen para sa pagbusong) - - [Check all that apply] Stool Blood Urine Others, specify: 5. Observed the following practices during pregnancy (Naga obserbar sang masunod): - [Check all that apply] Adequate and healthy eating ( Nagakadapat kag husto nga pagka on) Proper Hygiene (P aglimpyo sang kaugalingon) Adequate Exercise ( Husto nga ehersisyo) 6. Immunizations taken during pregnancy (Mga immunisasyon nga nabaton sat ion sang pagbusong?) Tetanus Toxoid
The succeeding questions is to be asked if there are children age less than 6 weeks old currently staying in the said household. ( Ang mga masunod nga pamangkot kay para lamang sa mga panimalay nga may bag-ong bata nga gapang edaron 6 ka doming panubo) BLOCK VIII: POST-NATAL CARE (PAGTATAP SA BATA) BLOCK IX : FAMILY PLANNING (PAGPLANO SANG PAMILYA) Flu Vaccine COVID- Others, specify:
7. Problems encountered from previous or current pregnancy (Problema natuhoy sa nagligad kag sang subong nga pagbusong?) - [Check all that apply] UTI Gestational Hypertension Gestational DM Others, specify: 8. Birth attendant ( Sin o ang nagpabata?) Doctor Hilot , trained Nurse Hilot , untrained Midwife Others, specify 9. Place of Delivery (Diin nagabata?) Hospital Municipal health center Balay Lying-in Clinics Brgy. Health Center Others, specify 10. Mode of Birth Delivery (Sahi sang pagbata) NSVD, pila CS, pila 11. Previous miscarriages (Kaagi ka na bala nga nahulugan?) Huo, pila Wala Reason of miscarriage (Ano ang rason nga nahulugan ka?) Aksidente Nahulogan Hungod Others, specify 12. How many days did the mother take a bath after childbirth (Ikapila nga adlaw naka paligo pagkatapos magbata?) Pagbata Pagkatapos 9 ka adlaw Pagkatapos 3 ka adlaw Pagkatapos 15 ka adlaw Pagkatapos 7 ka adlaw Others, specify: Cleaning of breast for breastfeeding (Paglimpyo sang suso para magpatiti) Tubig Others, specify : Tubig kag habon Cleaning of private areas ( Paglimpyo sang kinatawo ) Tubig Others, specify: Tubig kag habon 13. Bathing the child (Pagpaligo sang bata) Pagbata Pagkatapos 9 ka adlaw Pagkatapos 3 ka adlaw Pagkatapos 15 ka adlaw Pagkatapos 7 ka adlaw Others, specify: Cleaning of the umbilicus (Paglimpyo sang pusod ) Alcohol Bayabas Betadine Others, specify: Merthiolate Breastfeeding (Pagpatiti) Breastfed Mixed Bottle fed 14. Using a family planning method (Naga family planning bala kamo? ) Yes ( Huo ) No ( Wala) If yes, whose decision? (Kon Huo, kay sin o desisyon?) Self Doctor Both ( Amon nga mag asawa ) Neighbor ( Ingod balay) Nurse Others, specify:
2. Was a family member diagnosed with COVID 19? If yes, what diagnostic test was used? ( May ara bala miyembro sang pamilya nga nagka COVID-19? If huo, bal-an mo kung paano siya nadiagnose?) [ ] Yes [ ] No [ ] Rapid Antigen Test [ ] RT-PCR [ ] Others: 3. Where was he/she treated? (Sa diin siya gin bulong?) [ ] Home Quarantine [ ] Facility Quarantine [ ] Hospital (Private) [ ] Hospital (Public) 3. Do you use a mask when going outside the house? If yes, what type? (gagamit bala ikaw mask mag gwa sa inyo balay? If huo, ano nga mask?) [ ] Yes [ ]No [ ] 3-ply surgical mask [ ] KN95/KF [ ] N [ ] Cloth [ ] Others, specify 4. Do you bring rubbing alcohol when going outside the house? If yes, where do you get one? (Gadala ka bala alcohol mag gwa sa balay? If huo, diin ka gakuha?) [ ] Yes [ ]No [ ] Buy from Store [ ] Someone provides / may gahatag (Specify if who: ) [ ] Others, specify 5. Source of information about COVID-19? (Diin nagakuha sang imporsayon tuhoy sa COVID-19) - [Check all that apply]
[ ] TV
[ ] Radio [ ] Newspaper [ ] Internet (e.g. social media) [ ] Others, specify: —----------------------------------------------------------------------------END OF SURVEY—----------------------------------------------------------------------------- THANK YOU!
