Name: __________________________________

Gender: _________
Age: _____ Municipality: _________________
Greetings! We are 4th year students taking
up Bachelor of Science in Accountancy in
Lyceum of the Philippines UniversityCavite. We are currently conducting our
Feasibility Studies about Maternity and
Pediatric Hospital.
As part of this, we have to conduct a survey
to gain information about Maternal Health
Services. We would appreciate it if you will
participate in this survey.
Kindly answer it honestly.
1 Please indicate your postal code
below so that we can group child care
needs by area:
postal code: ______ ______
2 In general, do you think that families
in your community have access to an
adequate supply of child care
services?
Yes

No

Dont know

1. Do you have any children or infant in

your household?
Yes

No

2. How many are they?

1-2
2-4
5-6
More than 6

3. Which age groups your child belongs

to?
Birth-11 months

12-23 months (1 year old)

2-4 years
5-9 years
10-14 years

Date: ______________________

Occupation: ________________

4. Is your child male or female?

Male
Female
5. What is your relationship to the child?

Mother
Father
Grandmother
Grandfather
Aunt
Uncle

3 Where do you go first when your

child/kids got sick?

Relatives
Friends
Doctors
Others: __________________________

4 Where do you usually go when your

child is sick or needs health services?

Clinic
Health centre
Private Hospital
Public Hospital
Others: ___________________________

5 Who's the one making the decisions

where to consult?

Husband
Self
Both
Others: __________________________

6 How did you know the hospitals in

your vicinity?

Referral by doctors
Referral by friends
Self-search
Media

7 When do you consult the doctor for

the child's health?

General-check up
If Sick
If required
Others: __________________________

8 How many times do you consult the

doctor?

Once a year
Every month
Twice a month
Others: ___________________________

9 In case of emergency, where will you

bring your
child ?
Clinic
Private Hospital
Public Hospital
Others: ___________________________
10 Do you consider the aesthetic setting
of the hospital/clinic?
Yes

No

11 What is your monthly family income?

2000-5000
5000-10000
10000-20000
20000-50000
50000 Above

12 What do you consider in choosing the

hospital for providing your child's
health care?
Please Rank 1-4 (1 as the highest)
Environment
Doctor
Facilities
Hospital Rate

13 Do you consider Health care benefits

such as
Phil Health?
Yes

No

14 Do you have any other health care

benefits other than Phil Health?
Yes No
If Yes, What?
__________________________
Ma'am these are the additional questions
that I may include in the other survey
questions.
Additional Questions:
1. Who's the one making the
decisions where to consult?
Husband
Self
Both
Others:
_____________________________
2. Do you consider Health care
benefits such as
Phil Health?
Yes No
3. Do you have any other maternity
health care benefits other than
Phil Health?
Yes No
If Yes, What?
__________________________
4. Do you save money for your
pregnancy?
Yes No
5. How much money do you save for
the future Delivery?
2000-5000
5000-10000

10000-20000
20000-50000

50000 Above