COMMUNITY PROFILE

Name: Date:

Address:

Please take a minute to complete the survey below.

Thank you for your time and interest in helping us to identify our most pressing problems and issues.

A. COMMUNITY HISTORY

1. Please mark if you have the following conditions. Mark all that is applicable.
o Diabetes
o Heart disease
o Kidney disease
o Depression
o Sexually Transmitted disease
o Other: _________

2. Please select your most recent immunization. Please mark all that is applicable
o Tetanus
o Pneumonia
o Influenza
o Hepatitis B
o Other: _________

3. Have you had any of the following test done, please select if know:
o Cholesterol
o Pap smear/Pelvic
o Mammogram
o HIV
o Colonoscopy
o Other: _________

4. Do you smoke or use tobacco products?

o Yes
o No

5. Do you consume alcohol?

o Yes
o No

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Please mark all true statements.

Section I: Cardiovascular Risk Factor

___ you are a man older than 45 years. ___ You have a close relative who had a heart attack or
heart surgery before 55 (father or brother) or before age
___ You are a woman older than 55 years, have had 65 (mother sister).
postmenopausal.
___ You are a diabetic or take medication to control
___ You smoke, or quit within the previous 6 months. your blood sugar.
Are you interested in quitting? Y or N
___ You are a physically inactive (< 30 minutes of
___ You have been medically diagnosed withhigh blood physical activity on at least 3 days per week).
pressure (≥140/90). ___ You are >20 pounds overweight.

___ You have been medically diagnosed with abnormal ___ You have been medically diagnosed with sleep
cholesterol (i.e., HDL≤40mg/dL,LDL≥130mg/dL and/or apnea.
total cholesterol >200 mg/dL).

Section II. Cardiovascular History

You have had the following History: You have the following Symptoms:
___ Heart attack ___ Chest discomfort or angina with exertion.

___ Heart surgery, including heart catheterization or ___ Unreasonable breathlessness at rest or with exertion
coronary angioplasty.
___ Dizziness, fainting, blackout with exertions
___ Pacemaker/implantable cardiac defibrilator
___ Heart valve disease ___ Cramps or burning in your lower legs when walking
short distance
___ Abnormal Heart rhythm
___ Heart transplantation ___ Ankle swelling in one or both legs

___ Congenital heart disease/defect ___ Blood clot in your legs or lungs in the last 6 months

___ Asthma or other chronic lung disease In the past years, have you:
Had an exercise stress test? Y N
___Stroke Gained more than 20lbs Y N
Participated in a regular exercise program? Y N

Section III. Other Health Issues

Please check any of the following conditions you now ___ Emotional disorder (Type: _________ )
have or ever had:
___ Currently pregnant ___ Orthopedic problems

___ Cancer (Type: _________ ) ___ Exercise- induced injury

___ Neurological Condition (Type: _________ ) ___ Stomach/Digestive Problems

___ Seizures/Convulsion ___ Have impaired vision hearing or tactile sensation

___ Memory Issues

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___ Chronic pain condition

___ Balance or gait issues

___ Have experienced a fall in the past 6 months

___ Use an assistant device (i.e., cane or walker)

B. PHYSICAL, GEOGRAPHICAL, AND TOPOGRAPHICAL

CHARACTERISTICS

Barangay/District/Municipality/Province

 
 
1. What is the name of the nearest urban area? 
__________________________________ 
 
2. How far is it? (In km)  
__________________________________ 
 
3. What are the most commonly used types of transportation to go from this place? Pease
mark all applicable. 
___ Tricycle  
___ Bicycle
 ___Motorcycle
___ Car
___ Animals (Horse, Cow, Carabao) 
___ Walking 
Other: ___________________________  
  
4. What are the major economic activities of the people living in this locality? Please mark
all applicable
___ Agriculture 
___ Livestock 
___ Fishing 
___ Trading/marketing 
___ Manufacturing 
___ Mining 
___ Government 
Other: _____________________ 

5. How will you describe the internet connectivity in your place?

___ Strong
___ Moderate
___ Weak

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 6. How far is the nearest hospital? (In km)
__________________________________

C. DEMOGRAPHICS CHARACTERISTICS

1. Zip code where you live: ____________

2. Age: ___ 25 or less

___ 26 - 39
___ 40 - 54
___ 55 - 64
___ 65 or over

3. Sex: ___ Male ___ Female

4. Marital Status:
___ Married / co-habitating
___ Not married / Single

5. Education
___ Less than high school
___ High school diploma
___ College degree or higher
___ Other__________________

6. Household income
___ Less than ₱10,000
___ ₱11,000 to ₱29,999
___ ₱30,000 to ₱49,999
___ ₱50,000 and above

13. How do you pay for your health care? (check all that apply)
___ Pay cash (no insurance)
___ Health insurance (e.g., health card, Philhealth,)
___ Medicare
___ Other ____________________

14. Where / how you got this survey: (check one)

___ Church
___ Community Meeting
___ Grocery Store / Shopping Mall
___ Mail
___ Newspaper
___ Newsletter
___ Personal Contact
___ Workplace
___ Other ____________________

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 D. SOCIO- ECONOMIC AND CULTURAL CHARACTERISTICS

1. Ethnic origin: Please specify your ethnicity.

____________________ 
2. . How many people (NOT including yourself) live in your home? ____________

3. How many bedrooms (including guest bedrooms, bedrooms used as offices etc.) are in
the house or apartment which is your PRIMARY residence? ____________

____________have no primary residence

4. Which of the following best describes the highest level of educational you have
completed? Please mark.
o Didn’t Finish High School
o Didn’t Finish High School, but completed a technical/vocational program o High
School Graduate or GED (General Education Diploma)
o Completed High School and a technical/vocational program
o Less than 2 Years of College
o 2 Years of College or more/ including associate degree or equivalent
o College graduate (4 or 5 year program)
o Master’s degree (or other post-graduate training)
o Doctoral degree (PhD., MD, EdD, DVM, DDS, JD, etc)

Do you have firm plans for further education? Yes____ No____ If yes, what?
__________________________

5. What is your current employment status? Please mark ALL that apply.
o Working full time for pay → number of hours per week ________
o Working part time for pay → number of hours per week ________
o Not currently employed, looking for work
o Retired
o Homemaker
o Disabled (not working because of permanent or temporary disability)
o Other (please specify): _____________

6. Do you OWN your own home now (includes paying a mortgage)?

Yes____ No____

7. Do you OWN a working motor vehicle (car, truck, van, SUV) now?
Yes____ No____ If yes, how many do you own? _____

8. During the last year, did you take an out-of-town vacation?

Yes____ No____

9. Do you have a daily newspaper delivered to your home?

Yes____ No___

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 E. ENVIRONMENTAL VARIABLES

1. On which of the following platforms, have you heard about environmental pollution?
Mark all that apply.
o Television
o Radio
o Newspaper
o Internet
o Environment groupps
o Academic journals/special publications
o Others: __________________________

2. What is the level of trust on information about environmental pollution, if you were to
receive it from the following? Please put a check mark.

A lot A little Not very Not at all

much
Family
Friends
Blog and articles
Research papers
Social Media
Government entities
Scientific Journals

3. Please state your agreement with the following statements on environmental pollution :

Strongly Disagree Agree Strongly agree

disagree
It poses a hazard to the whole
world
Is on the rise
Is under control
My country has strong
environmental pollution laws
It is already impacting life as we
know it
It is causing extinction of flora
and fauna
There’s not much that can be
done to stop it
It is the Government’s
prerogative to deal with it
All of us have to contribute
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towards reducing it
Recycling helps
It is important to segregate waste
into dry, wet and recyclable
It is causing global warming
It is causing temperature change

4. On a scale of 1-10, please rate how environmental pollution affects your personal health
and safety where 1 affects you the least and 10 affects you the most
____1 ____6
____2 ____7
____3 ____8
____4 ____9
____5 ____10

5. Which of the following do you think impact and are the biggest causes of environmental
pollution? Choose only five of the following:
o Industrial activities
o Dumping solid waste
o Plastic consumption
o Vehicles
o Rapid urbanization
o Population over growth
o Combustion of fossil fuels
o Agricultural waste
o Deforestation
o Overfishing
o Lowered biodiversity

6. Which of the following do you think affect you the most?

o Air pollution
o Sound pollution
o Noise pollution
o Soil pollution

7. Are you aware of the global policies or initiatives taken by various organizations to
reduce environmental pollution?
Yes____
No____

8. Are you aware of your country’s laws to reduce environmental pollution?

Yes____
No____

9. Do you think that remedial action on environmental pollution should be the most
important aspect to take care of?
o No, there are bigger issues to resolve

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 o Yes, it is important as a few other issues
o Yes, it is the most important issues that needs to be resolved

10. How often do you recycle?

o Never
o Once in a while
o Most of the time
o Always

11. How often do you segregate waste?

o Never
o Once in a while
o Most of the time
o Always

12. How interested are you about preservation of the environment?

o Very uninterested
o Somewhat uninterested
o Somewhat interested
o Very interested

13. How likely are you to change your lifestyle to better suit the environment?

o Very unlikely
o Unlikely
o Likely
o Very likely

F. HEALTH AND ILLNESS PATTERNS

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 YES NO
Do you think that there are any conditions or illnesses which run in your
family? If so, please specify.

Have any of your close relatives had heart disease before the age of 60?
Please think about your parents, children, brothers and sisters. ‘Heart
disease’ includes cardiovascular disease, heart attack, and angina and
bypass surgery.

Have any of your close relatives had diabetes? Please think about your
parents, children, brothers and sisters. ‘Diabetes’ is also known as type 2
diabetes or non-insulin dependent diabetes.

Have any of your close male relatives had prostate cancer before the age of
60? Please think about your father, sons and brothers

Have any of your close female relatives had ovarian cancer? Please think
about your mother, daughters and sister

Have any of your close relatives had melanoma? Please think about your
parents, children, brothers and sisters.

Have any of your close relatives had breast cancer before the age of 50?
Please think about your parents, children, brothers and sisters.

Do you have more than one relative on the same side of the family who has
had breast cancer? Please think about your parents, children, brothers,
sisters, grandparents, aunts, uncles, nieces, nephews and grandchildren.

Have any of your close relatives had bowel cancer before the age of 55?
Please think about your parents, children, brothers and sisters. ‘Bowel
cancer’ is also known as colon cancer, rectal cancer or cancer of the large
bowel.

Do you have more than one relative on the same side of the family who has
had bowel cancer? Please think about your parents, children, brothers,
sisters, grandparents, aunts, uncles, nieces, nephews and grandchildren.

Do you have more than one relative on the same side of the family who has
had any type of cancer? Please think about your parents, children, brothers,
sisters, grandparents, aunts, uncles, nieces, nephews and grandchildren.

Do you have more than one relative on the same side of the family who has
had any of the following types of cancer? Brain, kidney, thyroid, stomach,
uterus/endometrial, pancreas. Please think about your parents, children,
brothers, sisters, grandparents, aunts, uncles, nieces, nephews and
Grandchildren.

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 G. MORTALITY AND MORBIDITY
Columns
1 2 3 4
Category Unit Under 5 5-14 15- 59 60
years years years years
and
over
A Moderate localized pain and/or mild Days
systemic reaction or impairment
requiring minor change in normal
activities, and associated with some
restriction of work activity 
B Moderate pain and/or moderate Days
impairment requiring moderate
change in normal
activities, e.g. house-bound or in bed,
and associated with temporary loss of
ability to work 
C Severe pain, severe short Days
term impairment, or hospitalization 
D Mild chronic disability (not requiring Cases
hospitalization, special care, or other
major limitation of normal activity,
and seriously restricting ability to
work) 
E Moderate to severe chronic disability Cases
(requiring hospitalization, special
care, or other major limitation of
normal activity, and seriously
restricting ability to work) 
F Total impairment  Cases
G Reproductive impairment resulting in Cases
infertility 
H Death Cases

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 H. HEALTH PROGRAM AND SERVICES

1. Is there a difference in performance between the available hospitals in this area?

o Yes
o No
o Not sure

2. Do you have a preferred hospital?

o Yes
o No

3. Do you receive pressure from other family members to get health care problems taken
care of promptly?
o Yes
o No
o Only sometimes

4. Do you feel comfortable judging the differences between hospitals in this area?
o Yes
o No
o Not sure

5. Do you receive care from the same hospital?

o Yes
o No
o Not sure

6. Can you be helpful to friends who are having difficulty making section of a hospital?
o Yes
o No
o Not sure

7. How many years have you lived in this community?

____________

8. How satisfied are you with the skill and competency of the staff?
o Very satisfied
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 o Somewhat satisfied
o Somewhat dissatisfied
o Very satisfied
o Not sure

9. Does the hospital you regularly visit have equipment for modern diagnosis and
treatment?
o Yes
o No
o Not sure

10. Does the hospital have modern operating room facilities?

o Yes
o No
o Not sure

11. Overall cleanliness of the hospital

o Very satisfied
o Somewhat satisfied
o Somewhat dissatisfied
o Very satisfied
o Not sure

12. Efficiency of nursing care

o Somewhat satisfied
o Somewhat dissatisfied
o Very satisfied
o Not sure

13. Friendliness and courtesy of staff

o Very satisfied
o Somewhat satisfied
o Somewhat dissatisfied
o Very satisfied
o Not sure

14. Convenience of location for you

o Very satisfied
o Somewhat satisfied
o Somewhat dissatisfied
o Very satisfied
o Not sure

15. Cost of health care

o Very satisfied
o Somewhat satisfied
o Somewhat dissatisfied
o Very satisfied
o Not sure
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 16. What kind of medical insurance coverage do you have?
o None
o Private
o Employee sponsored
o Medicaid
o Medicare
o Not sure
Other: ____________

17. How many times have you and any member of your family been to your doctor in the last
year? ____________

18. How many times have you visited a friend or loved one in the hospital in the last year?
____________

19. How many times have you and other members of your family been a patient in a hospital
in the last 3 years? ____________

20. If quality of service is equal, which source of care would you prefer?
o I would prefer to go to a walk-in clinic
o I would prefer to go to my personal physician
o I would prefer to go to the hospital emergency room
Other: ____________

I. POLITICAL AND LEADERSHIP PATTERNS

Please mark the number that represents how strongly you feel about the statement by using the
following scoring system

o Almost Always True- 5

o Frequently True- 4
o Occasionally True- 3
o Seldom True- 2
o Almost Never True- 1

1. I always retain the final decision making within my 5 4 3 2 1

department or team.

2 I always try to include one or more employees 5 4 3 2 1

in determining what to do and how to do it.
However, I maintain the final decision making
authority.

3 My employees and I always vote whenever a 5 4 3 2 1

major decision has to be made

4 I do not consider suggestions made by my 5 4 3 2 1

13
 employees, as I do not have the time for them.

5 I ask for employee ideas and input on upcoming 5 4 3 2 1

plans and projects.

6 For a major decision to pass in my department, 5 4 3 2 1

it must have the approval of each individual or
the majority

7 I tell my employees what has to be done and 5 4 3 2 1

how to do it.

8 When things go wrong and I need to create a 5 4 3 2 1

strategy to keep a project or process running on
schedule, I call a meeting to get my employee's
advice.

9 To get information out, I send it by email, 5 4 3 2 1

memos, or voice mail; very rarely is a meeting
called. My employees are then expected to act
upon the information.

10 When someone makes a mistake, I tell them not 5 4 3 2 1

to ever do that again and make a note of it.

11 I want to create an environment where the 5 4 3 2 1

employees take ownership of the project. I
allow them to participate in the decision
making process.

12 I allow my employees to determine what needs 5 4 3 2 1

to be done and how to do it.

13 New hires are not allowed to make any 5 4 3 2 1

decisions unless it is approved by me first.

14 I ask employees for their vision of where they 5 4 3 2 1

see their jobs going and then use their vision
where appropriate.

15 My workers know more about their jobs than 5 4 3 2 1

me, so I allow them to carry out the decisions
to do their job.

16 When something goes wrong, I tell my 5 4 3 2 1

employees that a procedure is not working
correctly and I establish a new one.

17 I allow my employees to set priorities with my 5 4 3 2 1

14
 guidance.

18 I delegate tasks in order to implement a new 5 4 3 2 1

procedure or process.

19 I closely monitor my employees to ensure they 5 4 3 2 1

are performing correctly.

20 When there are differences in role expectations, 5 4 3 2 1

I work with them to resolve the differences.

21 Each individual is responsible for defining his 5 4 3 2 1

or her job.

22 I like the power that my leadership position 5 4 3 2 1

holds over subordinates.

23 I like to use my leadership power to help 5 4 3 2 1

subordinates grow.

24 I like to share my leadership power with my 5 4 3 2 1

subordinates.

25 Employees must be directed or threatened with 5 4 3 2 1

punishment in order to get them to achieve the
organizational objectives.

26 Employees will exercise self-direction if they 5 4 3 2 1

are committed to the objectives.

27 Employees have the right to determine their 5 4 3 2 1

own organizational objectives.

28 Employees seek mainly security. 5 4 3 2 1

29 Employees know how to use creativity and 5 4 3 2 1

ingenuity to solve organizational problems.

30 My employees can lead themselves just as well 5 4 3 2 1

as I can.

Date completed: ________________________

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THANKYOU SO MUCH!!!
GOD BLESS!

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