Control #

GENDER
Male
Female
AGE
0-1
1-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
66-70
71-75
76-80
81-85
86-above
MARITAL STATUS
C
S
M
MS
W
WR
RELIGION
RC
P
INC
P
BAC
JW
M

10

11

12

13

14

15

18

19

20

21

22

M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M

others
EDUCATION
P
EL
EG
HL
HG
V
SC
CL
CG
PG
None
TYPE OF WORK
E/Employed
RF
RP
C
CW
CE
SE
S
UE/Unemployed
PLACE OF WORK
I
IM/C
O
OFW
PLACE
OF
FC
F
PLACE OF ORIGIN
NCR
CL
NL
SL
V

M
TYPE OF FAMILY
A. Compostion
Nuclear
Extended
Dyad
Single Parent
Homosexual/Same Sex
Cohabiting/Communal
B. Focus of Power
Patrifocal/Patriarchal
Matrifocal/Matriarchal
Egalitarian
Matricentric
C. Place of Residence
Patrilocal
Matrilocal
Bilocal
Neolocal
Avunvolocal
D. Descent
Patrilineal
Matrilineal
Bilateral
DIALECT
Hiligaynon (Ilonggo)
Ilocano
Kapampangan
Pangasinan
Tagalog
Waray
Others
Social Indicators
A. Services in the
Community
Religious Services
Health Services
Livelihood Services

Garbage collection
Peace and order
B. Institutional Facilities
Brgy. Hall
Health Station
Church
School
C. Organizations
Senior Citizen
Youth
D. Values/
Traditions/Customs
Bayanihan
Palabra De Honor
Pakikisama
Ningas Kugon
Fiestas
Close Family Ties
Respect for Elderly
E. Recreational Facilities
Volleyball/Basketball Court
Playground
Plaza
Others
F. Mode of Transportation
Tricycle
Jeep
Bicycle
Private Vehicle
G. Mode of Transportation
Postal System
Internet
Telephone
Cell-phone
Two-way Radio
Others

23

24

25

F M F M F M

TOTAL

Control #
ECONOMIC INDICATOR
Monthly Family Income
Less than 5000
5001-10000
10001-15000
15001-20000
20001-25000
25001-30000
30001-35000
35001-40000
40001-45000
45001-50000
50001 and Above
Financial Source of Family
Expenditures
Employment
Business
Pension
Help from Relatives
Others
Monthly Family Expenditures
Less than 5000
5001-10000
10001-15000
15001-20000
20001-25000
25001-30000
30001-35000
35001-40000
40001-45000
45001-50000
50001 and Above
Priorities and Expenditures
Food
Clothing
Education
Utilities
Health

10

11

12

13

14

15

16

17

18

19

20

21

Recreation
Savings
Adequacy of Family Income
Adequate
Not Adequate
CULTURAL INDICATOR
A. Cultural Orientation
Regarding Illness
Physiologic Factors
Supernatural Phenomenon
Punishment from God
Caused by Other Person
Change in Weather
B. Cultural Belief
GOD/ Other Spiritual Faith
Faith Healers
Supernatural Powers
Health Personnel
C. Cultural Practices
Always Practices
Sometimes Practices
Does not Practice
D. Community Involvement
Actively Join
Does not Actively Join
ENVIRONMENTAL INDICATOR
A. Home
1. Ownership
Owned
Rented
Rent-free
Least to Own
2. Construction Materials
Used
Light
Mixed
Strong
3. Number(s) of room used
for sleeping

1
2
3
4
5
4. Adequacy of Space
Adequate
Not Adequate
5. Lighting Facility
Electricity
Kerosene
Others
6. Adequacy of Lighting
Adeqaute
Not Adequate
G.7 Ventilation
Adequate
Not Adequate
8. General Sanitary Condition
Generally Clean
Dirty
B. Drinking Water Supply
1. Ownership
Private
Public
2. Source
Deep Well
Local Water District
Commercial
3. Potability
Yes
No
4. Storage
None
Large Covered Cointainer w/
Faucet
Large Unovered Cointainer w/
Faucet

Large Covered Cointainer w/o

Faucet
Large Unovered Cointainer w/o
Faucet
Others
5. Distance of Source of
Water
C. Food Storage/Cooking
Facilities
1. Foood Storage
Convered
Unconvered
2. Storage
Refrigerator
Cabinet
Basket
Table
3. Cooking Facilty
Electric Stove
Gas Stove
Firewood/Charcoal
4. Sanitary Condition
Generally Clean
Dirty
D. Waste Disposal
A. Refuse and Garbage
1. Storage
Container
None
2. Waste Segregation
Practiced
Not Practiced
2.1 If Practiced,
Method of
Disposal
Hog-feeding
Open Dumping
Burial in Pit
Collected
Composting
Open Burning
2.2 Reason for Practing

Environmentally Friendly
Use for Business
Barangay Ordinance w/c is
Stricly Monitored
Others
2.3 If Not Practiced,
Methods of Disposal
Hog-feeding
Collected
Open Dumping
Burial in Pit
Composting
Open
Burning
2.4 Reasons
For Not
Practicing
Not Aware of Effects
Long-time Practice of Family
No Time to do it
No Barangay/Municipality
Ordinance
B. Toilet Facilities
1. Ownership
Owned
Shared/Public
None
2.Type
Ballot System
Open-pit privy
Closed Pit Privy
Overhung Latrine
Antipolo Type
Water-sealed
Bored-hole Latrine
Flush Type
3. LocationOthers
From Source of
Water
Less than 20ft
More than 20ft
4. Sanitary Condition
Generally Clean

Dirty
C. Drainage System
Open Drainage
Blind Drainage
None
1. Condition
Flowing
Stagnant

22

23

24

25

TOTAL

Control #
A.Animals that are
Rabbies Carriers
Yes
No
B. Practices Done to
Control
Insects/Vectors of
Disease
Fumigation
Insecticides
Setting Traps
Cleaning the Yard
None
C. Presence of
Breeding Sites
Yes
No
D. Housing
Congestion
Yes
No
E. Presence of
Industrial
Establishment/
Factories
Yes
No
HEALTH AND ILNESS
PATTERN
1. Lifestly Practice
A. Use of Safety
Precaution
A.1 Use Safety
Devices when
necessary
Practice
Not Practiced
B. Cigarette Smoker

10

11

12

13

14

15

16

17

18

19

20

21

Yes
No
C. Use of Prohibited
Drugs
Yes
No
D. Drinks Alcoholic
Beverages
Yes
No
NUTRITIONAL
STATUS
A. Anthropometric
Data
BMI/WHR
Normal
Underweight
Overweight
Obese
A. Food
Usually/Most Taken
Meat Only
Fish Only
Vegetable Only
Mixed
Others
B. Number of
Servings
1
2--3
4-5 and Above
C. Second Choice
Meat Only
Fish Only
Vegetable Only
Mixed
Others

D. Number of
Servings
1
2--3
4-5 and Above
- Reason for
choices
It's healthy
Own preference
Affordable
Personal belief
Health condition
- Reason for not
choosing
It's healthy
Own preference
Not affordable
Personal belief
Health condition
- How frequent is
the intake
Everyday
Twice a week
Once a week
- Food prepared for
mealtime
Prepared at home
Bought outside
- How often
Everyday
Twice a week
Once a week
- If bought outside,
where?
Restaurant/Fast food
Carinderia
Food cart

- Reason for option

Convenience
Cheaper
Healthy
Variety of questions
- Takes/ eat
canned/ preserved
food
Everyday
Every other day
Every week
Sometimes
Never
- Takes/eat fried
foods
Everyday
Every other day
Every week
Sometimes
Never
- Drinks
carbonated
beverages
Everyday
Every other day
Every week
Occasionally
Sometimes
Never
+ Beliefs and
Practices
- Personnel mostly
consulted in times
of illness
Doctor
Nurse
Midwife

Hilot
Albularyo
Faith Healer
Elderly
- Measures taken
in times of sickness/
llness
Consult a private
health worker
Consult a Rural
Health Team
See a known
community healer
Self-Medication
- Medication taken
in times of sickness/
illness
Prescribed by doctor
Self-Medication/
Over the counter drugs
Herbals
+ Community
Health Programs
- Health Services
available in center
- Immunzation
Record
Complete according
to Age
Incomplete
according to age
Fully Immunized
Child
- Antenatal
Registration
Check Up
Regular

Not Regular
Without
Tetanus
Vaccination
With
Without
- Family Planning
Acceptor
Non-Acceptor
Reason
Good/ Bad for health
of family
Religious belief
Personal belief
Influenced by others
Methods Used:
Natural
Artificial
Permanent
+ Health Indicators
- Morbidity
Age
M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M
0-1
2-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
66-70
71-80

81-above
Gender
Female
Male
Cause
Intervention
With
Without
Admitted
Not Admitted
- Mortality
Age
0-1
2-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
66-70
71-80
81-above
Gender
Female
Male
Cause of death
False labor
Allergies
Heat Stroke
Leukocytosis
High-Blood Pressure

M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M

Colon Cancer/
Cancer
Others
- History/ Presence
of Non
Communicable
Disease
Age
M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M
0-1
2-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
66-70
71-80
81-above
Gender
Female
Male
NCD
Leukemia
High Blood
Colon Cancer/
Cancer
Others
- History/ Presence
of Communicable
Disease
Age
M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M
0-1
2-5

6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
66-70
71-80
81-above
Gender
Female
Male
Normal
+ Awareness of
health services
offered by the BHC/
RHU
Aware
Unaware

22

23

24

25

TOTAL

F M F M F M F M F

F M F M F M F M F

F M F M F M F M F

F M F M F M F M F