XVIII. HEALTH STATUS OF EACH MEMBER 1. Past illness for the last 6 months? __________________________________ 2.

Family Health History (acquired genetically) [ ] hypertension [ ] diabetes [ ] cancer [ ] others ___________ A. PRE AND POST NATAL CARE 1. Presently Pregnant __________________________________ Age of Pregnancy __________________________________ Expected date of Pregnancy __________________________________ 2. Did she have a pre-natal supervision? [ ] no [ ] yes To whom and where? ____________________ 3. Who have just delivered? ___________________________________ 4. Sex of the Baby? [ ] Boy [ ] Girl

5. Delivery Attendance [ ] Hilot [ ] Midwife [ ] Doctor [ ] Nurse [ ] Others _________________________ 6. Where was the baby delivered? [ ] at home [ ] at hospital [ ] private [ ] government 7. Did the baby have a well baby check up? [ ] No [ ] Yes To whom and where? ___________________ 8. What vaccination did the baby have? [ ] BCG [ ] DPT [ ] OPV [ ] Anti Measles 9. Other children: ___________________________________ Type of immunization ____________________________________ Reason not being immunized ____________________________________

B. NUTRITION 1. Approximately weekly budget for food? __________________________________ 2. Food items usually bought prepared and eaten __________________________________ 3. General impression of nutritional status

7. Eating Pattern (usual food) a. Common food for breakfast? _____________________________________ b. Common food for Lunch? _____________________________________ c. Common food for Dinner? _____________________________________

UNDERNOURISHED
A. Infants B. Pre- Schoolers C. Schoolers D. Adults

FAIRLY NOURISHED

D. COMMON PROBLEMS IN THE COMMUNITY 1. If somebody is ill. Who is the person to be approached? [ ] Brgy. Captain [ ] Brgy. Council [ ] Midwife [ ] Nurse [ ] Family [ ] others _______________ 2. For any activity project to be planned, who makes the decision? [ ] Brgy . Captain [ ] Brgy. Council [ ] People [ ] others________________

4. List of food items that the pregnant women eat [ ] Fish [ ] Meat [ ] Egg [ ] fruits [ ] vegetables [ ] Others _____________ 5. List of food items given to the baby after birth aside from milk? [ ] Ampalaya juice [ ] Am [ ] Honey [ ] others______________ 6. What food are usually given to your children for snack? [ ] boiled banana [ ] sandwich [ ] fruits [ ] others______________

D. FAMILY PLANNING 1. Desired number of Children? [ ]2 [ ]3 [ ]4 [ ] others_________________ 2. Methods preferred for fertility regulation [ ] Withdrawal [ ] IUD [ ] Pills [ ] Rhythm [ ] Condoms [ ] others___________ 3. Heard about family planning?if yes to whom? [ ] Yes [ ] No 4. Method presently using? How long? ___________________________________ E. GENERAL HEALTH BELIEFS AND PRACTICE 1. Understanding the common cause of illness of the people in the community. [ ]poor personal hygiene [ ] evil spirits [ ] night air [ ] inadequate food [ ] near highways [ ] others_____________ 2. When hospitals and health center are used? [ ] only when there is sick member of the family [ ] when there is pregnant woman who is about to deliver [ ] when children are needed to immunized

[ ] others(specify_________________________) 3. First person to be consulted in times of illness? [ ] Rural health Doctor [ ] Spiritista [ ] Albularyo [ ] Private Physician [ ] Nurse [ ] Midwife [ ] others ___________________ 4. Was there a family member who needed medical help But did not seek? [ ] yes [ ] no