AGE 0-11 mos.

1-4 5 to 9 10 to 14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65 &above

dea MALE

purok 2 charm mardi 0 1 0 0 0 1 1 0 0 1

gia

1 1

2 1

1 1

1 3 1 1

1 10

AGE 0-11 mos. 1-4 5 to 9 10 to 14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65 &above

0 0 0 1 1 1 1

2 1

2 1 1 1 2 2 1 1 1

1 2 1

12

CIVIL STATUS

Child Single Married Married but separeted Widow widower

1 5 2 1

5 1 2

6 7 4 1 22

RELIGION

9
Roman Catholic Protestant INC Born again Christian Jehovas witness Muslim Others

9 13

22
HIGHEST EDUCATION COMPLETED Pre-elem Elem. Level Elem. Undergrad Elem graduate Highschool Level Highschool undergrad Highschool graduate College Level College undergrad College graduate Post grad Vocational Short Courses None Not yet in age

2 1 1 1 1 2 1 1 1

2 1 2 2 2 7 1 1

1 4 2

2 2

2 2 22

Type of Work Regular full time Regular part time Contractual 6 mos.

1 1

4 1

Contractual every week Contractual every day Seasonal Self employed Unemployed Not yet in age to work

3 3

10 3 22

LOCATION Within the community Within the municipality Outside the municipality Outside the country

1 2

7 2 9

PLACE Office Factory Field

2 1

3 2

5 4 9

PLACE OF ORIGIN NCR Central Luzon Northern Luzon Southern Luzon Visayan Region Mindanao Region

1 8

9 2

10 10

2 22

LENGTH OF RESIDENCE 0-11 mos. 1-4 9-May 14-Oct 15-19 20-24 25-29

1 1 1 1 1 2

2 2 1

1 2

1 1

3 4 1 4 1 3 1

30-34 35-39 40-44 45-49 50-54 55-59 60-64 65 &above Membership Nuclear Extended Single Parent Dyad homosexual Cohabiting/common-law TOTAL Authority Matriarchal Patriarchal Egalitarian matricentric Patricentric TOTAL Location Patrilocal Matrilocal Neolocal

1 1 2

1 1 2

1 22

1 2

4 2

2 1

2 8

2 3 1 2

2 5 1

3 1

1 1

6 2 8

dominant Father Mother both Family Others

1 2 2 1

3 2 2 1 8

conflict
With

None

6 8

Discusses about it and the father decides on the issue/concern Discusses about it and the mother decides on the issue/concern Both parents discuss and decides on the issue All family members discuss and decides on the issue/concern Involves significant others no discussion at all

2 8

Monthly income(combined) less than 5,000 5,001 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 40,001 45,000 45,001 50,000 50,001 and above

1 2

6 2

Financial Source Employment Business Pension help from relatives/friends others,

1 8

Monthly family Expenditure less than 5,000 5,001 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 40,001 45,000 45,001 50,000 50,001 and above

Priorities and Expenditure Food Clothing Education utilities Health Recreation Savings

decision maker Father Mother both family others

1 2 1 1 1

3 1 3 1 8

Adequacy of family income adequate inadequate

1 1

7 1 8

Cultural orientation caused by physiologic factor e.g infections caused by supernatural phenomenon e.gkulam, balis a punishment from God caused by other person caused by change in weather others

2 1 2

2 3 8

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

2 1 3 2

2 6 8

Cultural practice always practices local cultural practice about health matters sometimes local cultural practice about health matters never local cultural practice about health matters

2 1 3 2

2 6

Community Involvement

2
actively joins fiesta, religious processions, local cultural practices does not actively join

2 2 4 8

2 1

a.

Ownership

owned rented rent- free lease to own

2 1

2 1

4 2 8

Construction materials used light mixed strong TOTAL a. Number of rooms used for sleeping: 0 1 2 3 4 5 TOTAL

2 1 1 1 1

2 1

4 2 2 8

2 1 1 1

1 1 1

3 3 2

a. adequate inadequate

Adequacy of space

2 1 2 3

2 6 8

a. electricity kerosene others TOTAL

Lighting facility

a.

Adequacy of lighting

adequate inadequate

1 1

6 8

total

a. adequate inadequate TOTAL

Ventilation

1 1

8 8

water supply
a. Ownership

private/own household use Public TOTAL

1 1

8 8

a. deep well

Source

local water district commercial TOTAL

1 2 1

2 3

3 5 8

a. yes no

Potability

1
TOTAL

8 8

a.

Storage

none (direct from faucet or pipe) large covered container with faucet

1 2

2 3

3 5

large uncovered container without faucet TOTAL

a. refrigerator cabinet basket table TOTAL

Storage

1 2 1 1
If table:

2 2 4 8 4 4

covered uncovered TOTAL

1 1

a.

Cooking facility

electric stove gas stove firewood/charcoal TOTAL

2 1 1

1 2

5 3 8

1.

Storage

plastic bag None Container TOTAL If container: Open Covered TOTAL

2 1 1

7 1 8

1.

Waste Segregation

Practiced not practiced TOTAL

2 1 1

7 1 8

If practiced: method of disposal hog feeding open dumping

burial in pit collected composting TOTAL

7 7

Reason for practicing: environmental friendly barangay ordinance used for business others TOTAL If NOT practiced: method of disposal hog feeding open dumping burial in pit open burning garbage collection Composting TOTAL

2 3

4 3

1 1

1 1

Reason for not practicing not aware of effects no time to do it long time practices of family not a barangay ordinance/not strictly monitored

1
toilet facilities 1. owned shared/public none TOTAL 1. Location from source of water Ownership

2 3

5 3 8

less than 20 ft 20 ft. and beyond TOILET balot open pit close pit overhung latrine antipolo type water sealed bored hole latrine others TOTAL

2 1 2 3

2 6

Drainage open drainage blind drainage none

8 8

Condition flowing stagnant TOTAL

Presence of animals that are rabies carriers with without TOTAL

5 1 1

1 1

6 2 8

Kind Dog Cat TOTAL

3 2

5 2 7

Where Kept Inside the yard

Free roaming TOTAL

1 7

Vaccination With regular vaccination Without vaccination TOTAL

3 2

4 3 7

practices to control insect Fumigation Insecticides setting traps cleaning the yard None TOTAL

3 1 1 2 2 2

3 5 8

presence of breeding sites None With TOTAL

2 1 1

1 2

5 3 8

FLIES MOSQUITOES

TOTAL

home Very good Good Poor

1 2

6 2 8

water Very good Good Poor

2 1 2 3

2 6 8

food and waste management Very good Good Poor

2 1 2 3

2 6 8

PRESENCE OF INDUSTRIAL
yes none TOTAL IF YES: small scale large scale

1 1

KIND OF NEIGHBORHOOD
accommodating approachable Friendly busy refusing not available TOTAL

1 1

1 6

1 1

1 8

Takes a bath regularly

PRACTICE always sometimes NOT PRACTICE

Brushing the teeth

PRACTICE always sometimes NOT PRACTICE

2 1 3 2 8

Hand washing before/after eating

PRACTICE always sometimes NOT PRACTICE

2 1 3 1 1 7 1

Nail Cutting

PRACTICE always sometimes NOT PRACTICE

2 2

6 2

Use of Hygienic Products

PRACTICE always sometimes NOT PRACTICE

3 1

1 1

6 2

Ear Cleaning

PRACTICE always sometimes NOT PRACTICE

3 1

2 2

5 3

Regular change of clothes

PRACTICE always sometimes

2 1 3 2 8

NOT PRACTICE sleeps 8 hours PRACTICE always sometimes NOT PRACTICE

2 1 3 2

2 3 3

takes nap/ rest period with in the day

PRACTICE always sometimes NOT PRACTICE

Perform Regular exercise everyday

2 1 3 2

2 3 3

PRACTICE always sometimes NOT PRACTICE

Performs recreational activities

2 2 1 3

2 2 4

PRACTICE always sometimes NOT PRACTICE 1 3

2 2

2 2 4

Has regular medical checkup (once a year

PRACTICE always sometimes NOT PRACTICE 1 3 2

2 6

Has regular dental checkup ( every months

PRACTICE always

sometimes NOT PRACTICE 1 3 2 2 8

Use safety devices when necessary

PRACTICE always sometimes NOT PRACTICE

6 2

smoker yes no

2 1 3

total
If yes, #of smoker

4 4 8

total

If yes, age of smoker < 10 years old 10 TO 14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65 & above

Age started smoking < 10 years old

10 to 14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65 & above TOTAL

Years of smoking

< 1 year 1 to 4 5 to 9 10 to 14 15 -19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65 & above TOTAL

Frequency < 5 sticks per day 5-9 sticks per day 10-14 sticks per day 15-19 sticks per day 1 pack

1 1

1 1

2 packs 3 packs 4 packs 5 packs & above TOTAL

alcohol drinker yes no

2 1 3

total
If yes, #of Alcoholic Beverages drinker

4 4 8

total

If yes, age of Alcoholic Beverages drinker < 10 years old 10 to 14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65 & above

2 2

2 2

Age started drinking Alcoholic Beverages < 10 years old 10 to 14 15-19 20-24 25-29 30-34 35-39 40-44

45-49 50-54 55-59 60-64 65 & above TOTAL

Years of drinking Alcoholic Beverages

< 1 year 1 to 4 5 to 9 10 to 14 15 -19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65 & above TOTAL Frequency Everyday Every other day Every week Every month Every year occasionally

3 4

Kinds of Alcohol BEER

TOTAL

Volume intake/bottle(s) per drinking spree 1 bottle 2-3 bottles 4-5 bottles 6-7 bottles 8-9 bottles 10 bottles & above TOTAL

2 2

2 2

BMI N Normal (within 2SD of median IRS) UW Underweight (< -2SD of median IRS OW overweight (> + 2SD of median IRS TOTAL

First Choice meat only Fish only vegetable only mixed others TOTAL

2 1 1 1

1 1

5 1 2 8

Number of Servings: 1 2--3 4-5 & above

1 2

2 2 2

3 5

TOTAL

Second choice meat only Fish only vegetable only mixed others TOTAL

3 1 1

1 1

1 1

1 5 2 8

Number of Servings: 1 2--3 4-5 & above TOTAL

1 1

1 2

2 2

3 5 8

Reasons for choices

2
think its healthy own preference affordability personal belief/practice health condition TOTAL

3 1 2

5 1 2

Reason for not choosing other options not healthy own preference not affordable personal belief/practice health condition TOTAL

2 1 2 1 2

2 3 3

From above response, how frequent is the intake?

2
everyday every 3 days once a week others TOTAL

3 2

6 2

How is food prepared for mealtime?

2
prepared at home bought outside TOTAL

1 1

8 8

How often?

2
everyday every 3 days once a week others TOTAL

1 1

7 1

If bought outside, is it from a: restaurant/fast food carinderia Food Cart TOTAL

Reason for above choice convenience cheaper healthy variety of choices others TOTAL

Takes/eat canned preserved food ex. Lucky me, maling Everyday every other day every week Sometimes Never TOTAL

2 1 1 3 2

2 6 8

Takes/ eat fried foods everyday every other day every week sometimes never TOTAL Drinks carbonated drinks

1 2 3 1 2 2

1 4 3 8

occasionally weekly everyday TOTAL

1 1

7 1 8

History/Presence of Non Communicable Diseases in the Family Heart dse Hpn Cancer Kidney dse Dm

3
TOTAL

History/Presence of Communicable Diseases in the Family

Chicken pox Measles

TOTAL

Blood Pressure Record for ages 35 above

Blood pressure below normal range Blood pressure within normal range Blood pressure above normal range

2 1

3 1

3
TOTAL

Complete accdg to age Imcompleteaccdg to age Fully immunized child TOTAL

Personnel mostly consulted in times of sickness doctor nurse midwife hilot albularyo faith healer elderly TOTAL

3 1

6 1

1 1

1 8

Measures taken in times of sickness/illness consult a private health worker see a known community healer consult a rural health team self-medicate none TOTAL

1 2 1 2 2

1 2 5

Medication/treatment in times of sickness/illness prescribed by doctor over the counter/ self-medication herbals others TOTAL

2 1 3 2

2 6

# of pregnant women ASOG

TOTAL

Regular Check-up Not Regular Check up Without Tetanus Check up regular not regular

without

Family Planning

2
acceptor non acceptor TOTAL

1 3 1

5 3 8

Reason for accepting

2
good for health of family personal belief religious belief influenced by others others TOTAL

1 1

1 5

Reason for NOT accepting good for health of family personal belief religious belief influenced by others others TOTAL

Methods used:

2
Natural artificial permanent TOTAL

2 1 1

4 1 5

Awareness of health Services offered by the BHC/RHU

2
Aware unaware TOTAL

1 1

8 8

Recognized leader and any key person

2
Brgy. Captain Kagawad Elderly BHW Influential person Religious Leader Neighbor TOTAL

Conditions/events/issues that causes social conflict/upheavels within the community gossip drugs alcohol drinking personal/familial conflict riot TOTAL

2 1 1 3

4 4 8

Practices/Approachesthat are effective in setting issues and concerns within the community

settelement among involved parties

1
brgy. Hearing endorsed local pulice TOTAL