QUESTIONNAIRE: (Based from Nursing Practice in the Community by Maglaya, A. 1. Family Structure, Characteristics, and Dynamics Istruktura sa pamilya, mga Kinaiya ug Kauswagan Name Pangalan Position in the family Puwesto sa pamilya Age Edad Sex Kasarian Civil Status (single, married, divorced) (Single, Minyo, Buwag) Address Pangalan sa lugar asa nag puyo 1.1. Who makes the decision when it comes to health? Kinsa ang naay tagtungod sa mga desisyon bahin sa mga butang panglawas? ______________________________________________________________________________ ______________________________________________________________________________ 1.2. Explain your relationship with the other family members? Unsa imong maikasulti sa imong relasyon sa isig ka myembro sa imong pamilya? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 2. Socio-economic and Cultural Characteristics Socio-ekonomiko ug Kultural na mga Kinaiya Name Pangalan Work Trabaho Place of Work Pangalan sa Trabahoanan Estimate Salary Banabana sa sweldo Educational Attainment Edukasyon 2.1. Who makes the decisions when it comes to money and how it is spent? Kinsa ang naai tigtungon sa mga desisyon bahin sa kwarta ug sa mga gasto-onon? Religion Relihiyon ______________________________________________________________________________ ______________________________________________________________________________ 2.2. Explain your situation on your family’s adequacy to meet the basic necessities? Unsa imong maikasulti bahin sa situasyong pang-adlaw adlaw, sa batakang mga kinahanglanon, sa inyong pamilya? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 2.3. Are there any persons or relatives who plays a role in supporting your family? Aduna bay mga taw o mga paryente nga inyong masampit sa mga panahon nga kamoy manganihanglan ug supporta? ______________________________________________________________________________ ______________________________________________________________________________ 2.4. What is your opinion about the services and programs given by your local health community? Unsa imong maikasulti bahin sa mga serbisyo ug programa nga ginahatag sa inyong sentro (Community Health Center)? Expand questions. Add Programs i.e. prenatal, vaccination, etc. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 3. Home and Environment 3.1. Explain your situation when it comes to your living condition? Unsa imo maikasulti bahin sa inyong panimalay? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 3.1.1. Does it have adequate living space? Para sa imoha, sakto ra sa lugar? Dili ra hu-ot? ______________________________________________________________________________ ______________________________________________________________________________ 3.1.2. How about your sleeping arrangement? Ang puwesto ninyo inig katulog? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 3.1.3. Did you notice any breeding or resting sites of vectors of diseases (e.g. mosquitoes, roaches, flies, rodents, etc.)? Aduna kay nabantayan na mga puy-anan sa mga mananap na makadala ug sakit, pareha sa mga lamok, uk-ok, langaw, ilaga ug uban pa. ______________________________________________________________________________ ______________________________________________________________________________ 3.1.4. In your opinion, did you see any presence of accident hazards in your place? Sa imong opinyon, aduna kay nakit.an nga dapit sa inyoha nga risko sa accidente? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 3.1.5. Where do you store and cook your food? Asa man mo mag hipos ug luto sa inyong mga pagkaon? ______________________________________________________________________________ ______________________________________________________________________________ 3.1.6. Where do your get your water supply? Asa mo ug tubig ikaligo ug mainom? ______________________________________________________________________________ ______________________________________________________________________________ 3.1.7. Do you have access to a toilet in your house? Naa ra moi kaugalingon nga kasilyas sa inyong panimalay? ______________________________________________________________________________ ______________________________________________________________________________ 3.1.8. Describe your methods for garbage disposal? Unsa inyong pamaagi sa pablabay sa basura? ______________________________________________________________________________ ______________________________________________________________________________ 3.1.9. Describe the type of drainage system in your area? Asa muagas ang ginamit na tubig sa inyoha? Naai kanal? Unsa nga klase? Naai tabon? Unsa imo maikasulti sa kalimpyo? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 3.2. Do you own the property you are living in? Ikaw ang tag-iya o nag-abang ka sa lugar kung asa ka nagpuyo? ______________________________________________________________________________ ______________________________________________________________________________ 3.3. Describe your relationship with your neighbors? How far is your next neighbor from your house? Unsa imo maikasulti, bahin sa relasyon nimo sa imong mga silingan? Unsa kalayo ang imohang sunod na silingan? ______________________________________________________________________________ ______________________________________________________________________________ 3.4. What type of communication tools you predominantly use? Unsa imong kasagaran gamiton para sa pag komunikar? Cellphone? Internet? ______________________________________________________________________________ ______________________________________________________________________________ 3.5. What do you use for transportation? Unsa ang inyohang ginagamit para sa transportasyon? ______________________________________________________________________________ ______________________________________________________________________________ 4. Health Satus of each family member? 4.1. Do you or any of your family members have any medical history of illnesses? Cancer, Hypertension or Diabetes? Naa moi kaliwat nga nasakit sama sa kanser, high-blood pressure ug diabetes? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 4.2. What is your usual everyday diet? Unsa ang kasagaran ninyong kanoon matag adlaw? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 4.3. Is anyone in your family smokes cigarette? Naai sa inyohang pamilya nga manigarilyohay? ______________________________________________________________________________ ______________________________________________________________________________ 4.4. When was the last time you had a laboratory test? What test? When? What was the result? Kanus-a ang ulahi nimong pa test sa laboratory? Unsa nga test? Kanus-a? Unsai resulta? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 5. Values, Habits, Practices on Health Promotion, Maintenance and Disease Prevention 5.1. Has everyone in the family received any type of vaccine? Nakapa bakuna na ba ang tanan sa pamilya? Unsa na mga bakuna? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 5.2. Describe your lifestyle pertaining to health practices such as sleep and rest, exercise, use of protective measures such as footwear, use of bed nets, clothing, use of face mask during COVID-19 pandemic, and any relaxation and leisure activities to manage stress. Unsa ang klase klaseng buluhatonon nimo patungod sa maayong panglawas sama sa pagkatulog, ehersisyo, pag gamit sa mga butang pang proteksyon sama sa tsinelas/sapatos, pag gamit ug muskitero, ug pag gamit ug face mask labaw na sa panahon sa pandemyang COVID-19? Unsa pud imong mga binuhatan nga pampalingaw para pa wala sa stress? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
