Legend:

Male Female

Civil Status:

Child Single Married Married but separated Widow Widower

Religion:

Roman Catholic Protestant Iglesia ni Cristo Born Again

Christian Jehovahs Witness Muslim Other

Education:

Pre Elem Elem. Level Elem. Grad High School level High School Grad Vocational Short courses College level College Grad Post Grad None- over 7 y/o without formal schooling

Place of Origin:

Metro Manila Central Luzon Northern Luzon Southern Luzon Visayan Region Mindanao Region

Type of Work:

Employed Regular Full Time Regular Part Time Contractual 6 Mos. Contractual every week Contractual every day Self-Employed Unemployed

Place of Work Location:

Within the community Within the muni/city Outside the muni/city Outside the country

Place:

Office Factory/Shop Field Institution

Type of Family:

Nuclear Extended Single Parent Dyad Homosexual Cohabiting/common-law Matriarchal Patriarchal Egalitarian Matricentric Patricentric Patrilocal Matrilocal Neolocal

Dialect Frequently Used: ________________________________________________________________________________________________________________________________________

II. Social Indicators

Services in the community:

Religious Services Livelihood Seminar Health Services Garbage Collection Peace and Order

Institutional Facilities:

Brgy. Hall Health Station Church School

Organizations: Senior Citizens youth

Values/Tradition/Customs:

Bayanihan Palabra de Honor Pakikisama Ningas kugon Fiestas Close Family Ties Respect for Elderly

Recreational Facilities:

Volleyball/Basketball Court Playground Plaza Others.

Mode of Transportation:

Tricycle Jeep Bicycle Private Vehicle

Mode of Communication:

Postal System Internet Telephone Cell phone Two-way Radio Others

Economic Indicator

Monthly Family Income (combined)

Less than 5,000 5,000 10,000 10,001 15,000 15,001 20,000 20,001 25,000 25,001 30,000 30,001 35,000 35,001 40,000 35,001 40,000 45,001 50,000 50,001 and above

Financial Source for Family Expenditures:

Employment Business Pension Help from relative/friends Others

Monthly Family Expenditure:

Less than 5,000 5,000 10,000 10,001 15,000 15,001 20,000 20,001 25,000 25,001 30,000 30,001 35,000 35,001 40,000 45,001 50,000

Priorities and Expenditure (familys priority by ranking 1-7 where 1 is the highest priority):

Food Clothing Education Utilities Health Recreation Savings

Decision Maker in terms of financial aspect:

Father Mother Both Family Others

Adequacy of Family Income:

Adequate Not Adequate

Cultural Indicator

Cultural Orientation regarding illness

Believe that illness is caused by physiologic factors e.g. Infection Believe that illness is caused by supernatural phenomenon e.g. Kulam Believe that illness is a punishment from God Believe that illness is caused by another person Believe that illness is caused by change of weather Other

Cultural Belief:

Health can be restored by God/ other spiritual faith Health can be restored by faith healers Health can be restored by supernatural power e.g. Tawas, hula Health can be restored by health personnel e.g. doctors, nurses

Cultural Practices:

Always practices local cultural practices about health matters Sometimes practices local cultural practices about health matters Does not practices local cultural practices about health matters

Community Involvement:

Actively joins fiesta, religious procession, local cultural practices Does not actively join

Environment Indicator

Home a. Ownership:

Owned Rented Rent-free Least to own

b. Construction of materials used:

Light Mixed Strong

c. Number of rooms and person used for sleeping: _______________________________________________________________________________________________________________

d. Adequacy of Space:

Adequate In adequate

e. Lighting Facility:

Electricity Kerosene Others

f.

Adequacy of lighting:

Adequate In adequate

g. Ventilation:

Adequate In adequate

Drinking Water Supply a. Ownership:

Private/Own household use Public

b. Source:

Deep Well Local Water District Commercial

c. Portability

Yes No

d. Storage:

None (direct from the faucet or pipe) Large covered container with faucet Large uncovered container without faucet Other

Food Storage/Cooking Facilities a. Storage:

Refrigerator Cabinet Basket Table Covered Uncovered

b. Cooking Facility:

Electric Stove Gas Stove Firewood/Charcoal

c. Sanitary Condition: _____________________________________________________________________________________________________________________________________

Garbage/Waste Disposal a. Storage:

Container Covered Uncovered Plastic bag None

b. Waste Segregation:

Practiced Not Practiced

*If practiced Method of disposal: Biodegradable:

Hog-feeding Open dumping Collected Composting Burial in pit

Non-biodegradable:

Recycle Reuse Collected Open burning Open dumping Other

Reason for practicing:

Environmentally Friendly Barangay ordinance which is strictly Monitored Use for business Other

*If not practiced, Method of Disposal:

Open dumping Burial in pit Open buring Garbage Collection Other

Reason for not practicing:

Not aware of Effects No time to do it Long-time practice of family Not a brgy. Ordinance/ not strictly monitored

Toilet Facilities

Ownership:

Owned Shared/Public None

Type:

ballot system Open pit privy Closed pit privy Overhung latrine Antipolo type Water-sealed Broke-hole latrine Others

Location from Water Source:

Less than 20 ft 20 ft beyond

Sanitary Condition: ___________________________________________________________________________________________________________________________________________

Drainage System:

Open Drainage Blind Drainage None

Condition:

Flowing Stagnant

Presence of Animals that are rabies carriers

Animals raised: Where Kept Inside the Yard / Outside.free

Kind

Number

With regular Vaccination

Without Vaccination

Measures done to control insects/vectors of diease:

Fumigation Insecticides Setting Traps Cleaning the yard None

Presence of breeding sites:

With None

*** For observation only House Congestion:

Yes No

Presence of Industrial establishments/factories:

Yes NO

III. Health and Illness Pattern Lifestyle practices (according to family)

Hygiene

Practice 1. Taking bath regularly 2. Brushing the teeth 3. Hand washing before and after eating 4. Nail cutting 5. Use of hygienic products 6. Ear cleaning 7. Regular change of clothes

Not Practiced

Rest and Sleep

1. Sleeps at least 8 hrs per day 2. Takes nap / rest period with in the day

Exercises

Practice 1. Perform regular exercise everyday 2. Perform recreational activities

Not Practiced

Health Promotion Activities

1. Has regular medical checkup (once a year) 2. Has regular dental checkup (every 6 months)

Use of Safety Precaution

Use safety devices when necessary E.g. helmet, safety belts

Is there a member in your family that is a cigarette smoker?

( ) Yes

( ) No

Age

Age Started Using

Reason

Use of probihited / dangerous drugs

( ) Yes ( ) No

Drinks Alcoholic beverages:

Age

Age started drinking

Frequency

Reason

Dietary history Food usually / most taken First choice

Meat only Fish only Vegetable only Mixed Others

Number of servings:

1 2-3 4-5 and above

Second choice:

Meat only Fish only Vegetables only Mixed Others

Reason for choices:

Think its healthy Own preference Affordable Personal belief / practice Health conditions

Reasons for not choosing other options:

Not healthy Own preference Not affordable Personal belief / practice Health conditions

From the above response, how frequent is the intake?

Everyday Every 3 days Once a week Others

How is food prepared in meal time?

Prepared at home But outside

How often?

Everyday Every 3 days Once a week Others

If bought outside, is it from the:

Restaurant / fast food Carenderia Food cart, ex.KFC,pusit,provence

Reason for the above choice:

Convenience Cheaper Healthy Variety of choices Others

Takes / eat canned / preserved food. Ex. Lucky me, maling:

Everyday Every other day Every week Sometimes Never

Takes / eat fried foods:

Everyday Every other day Every week Sometimes Never

Drinks carbonated beverages:

Occasionally Weekly Everyday

Beliefs and Practices

Personnel mostly consulted in times of sickness / illness:

Doctor Nurse Midwife Hilot Albularyo Faith healer Elderly

Measures taken in times of sickness:

Consult a private health worker Consult a rural health team See a known community healer Self medicate None

Medication/ treatment taken in times of sickness/ illness:

Prescribed by doctor Over the counter/ self medication Herbals Others

Community health programs Immunization record ( 0-12 months)

Age in months

Sex

BCG

DPT 1

DPT 2

DPT 3

Hepa B 1

Hepa B 2

Hepa B 3

OPV 1

OPV 2

OPV 3

Measles

Complete ACCDG to age

Incomplete ACCDG to age

FIC

Antenatal Registration:

AOG

PRENATAL CHECK UP WITH REGULAR NOT REGULAR WITHOUT WITH

TETANUS TOXOID VACCINATION WITHOUT

FAMILY PLANNING

ACCEPTOR:

Good for health of family Personal belief Religious belief Influence by others

NON ACCEPTOR:

Bad for health of family Personal belief Religious belief Influence by others Others

Methods use:

Natural Artificial Permanent