Legend: Sex : M male F female Civil Status: C - child Religion: RC Roman Catholic S single P Protestant M married INC Iglesia

glesia ni Cristo MS married but BACBorn Again Christian separated JW Jehovas Witness W widow M Muslim Wr- widower Others, specify:________

P - Pre-elem CL College level Place of Origin: EL elem. Level CG College NCR Metro Manila EG elem. Grad PG post grad CL Central Luzon HL High School level NL Northern Luzon HG High School grad SL Southern Luzon V Vocational V Visayan Region SC Short courses M Mindanao Region None over 7 y/o without formal schooling Type of Work: Place of work: E employed Location: I within the community RF regular full time IM/C within the municipality/city RP regular part time O outside the municipality/city C contractual 6 mos. OFW outside the country CW contractual every week CE contractual every day Place: OF office FC factory l FL field SE self-employed (with sari-sari store, poultry, other business) S seasonal UE unemployed Education : a. Type of family: ( ) nuclear ( ) Dyad ( ) matriarchal ( ) matricentric ( ) extended ( ) single parent ( ) homosexual ( ) cohabiting/common-law ( ) patriarchal ( ) patricentric ( ) egalitarian

B. Institutional facilities: ( ) brgy. Hall ( ) health station ( ) church ( ) school C. Organizations: ( ) senior citizens ( ) youth D. Values/tradition/customs: ( ) bayanihan ( ) palabra de honor ( ) pakikisama ( ) ningas kugon ( ) fiestas ( ) close family ties ( ) respect for elderly E. Recreational facilities: ( ) Volleyball/basketball court ( ) playground ( ) plaza ( ) others, specify: __________ F Mode of transportation: ( ) tricycle ( ) jeep ( ) bicycle ( ) private vehicle G. Mode of communication: ( ) postal system ( ) internet ( ) telephone ( ) cell phone ( ) two-way radio ( ) others, specify: _______ 2. Economic Indicator A. Monthly family income (combined) ( ) less than 5,000 ( ) 20, 001 25,000 ( ) 40,001 45,000 ( ) 5,000 10,000 ( ) 25,001 30,000 ( ) 45,001 50,000 ( ) 10,001 15,000 ( ) 30,001 35,000 ( ) 50,001 and above ( ) 15,001 20,000 ( ) 35,001 40,000 B. Financial Source for Family Expenditures ( ) employment ( ) business ( ) pension ( ) help from relative/ friends ( ) others:______ C. Monthly family expenditure ( ) less than 5,000 ( ) 20, 001 25,000 ( ) 40,001 45,000 ( ) 5,000 10,000 ( ) 25,001 30,000 ( ) 45,001 50,000 ( ) 10,001 15,000 ( ) 30,001 35,000 ( ) 50,001 and above ( ) 15,001 20,000 ( ) 35,001 40,000 D. Priorities and Expenditure ( familys priority by ranking 1-7 where 1 is the highest priority) ( ) food ( ) clothing ( ) education ( ) utilities ( ) health ( ) recreation ( ) savings E. Decision maker in terms of financial aspect ( ) father ( ) mother ( ) both ( ) family ( ) others F. Adequacy of family income (as perceived): ( ) adequate ( ) not adequate 3. Cultural Indicator A. cultural orientation regarding illness ( ) believe that illness is caused by physiologic factor e.g. infection ( ) believe that illness is caused by supernatural phenomenon e.g. kulam, balis ( ) believe that illness is a punishment from God ( ) believe that illness is caused by other person ( ) believe that illness is caused by change in weather ( ) others: ______ B. cultural belief: ( ) health can be restored by God/ other spiritual faith

( ) patrilocal ( ) matrilocal ( ) neolocal b.Dialect frequently used: ________________________ II.Socio-economic, cultural and environmental 1. Social Indicators (for observation / key informant interview) A. Services in the community: ( ) religious services ( ) livelihood seminar ( ) health services ( ) garbage collection ( ) peace and order

( ) health can be restored by faith healers ( ) health can be restored by supernatural power e.g. Tawas, hilot, hula ( ) health can be restored by health personnel e.g. doctors, nurses C. cultural practices ( ) always practices local cultural practices about health matters ( ) sometimes practices local cultural practices about health matters ( ) does not practice any local cultural practices about health matters D. Community Involvement ( ) actively joins fiesta, religious procession, local cultural practices ( ) does not actively join 4. Environment Indicator A. Home a. Ownership: ( ) owned ( ) rented ( ) rent-free ( ) least to own b. Construction materials used: ( ) light ( ) mixed ( ) strong c. Number of rooms and person used for sleeping: _____________ d. Adequacy of space: ( ) adequate ( ) inadequate e. Lighting facility: ( ) electricity ( ) kerosene ( ) others, specify __________ f. Adequacy of lighting: ( ) adequate ( ) inadequate g. Ventilation: ( ) adequate ( ) inadequate h. General sanitary condition: __________________________ B. Drinking Water Supply a. ownership : ( ) private/own household use ( ) public b. source: ( ) deep well ( ) local water district ( ) commercial c Potability (as perceived) : ( ) Yes ( ) No d. Storage: ( ) none (direct from the faucet or pipe) ( ) Large covered container with faucet ( ) Large uncovered container without faucet ( ) Others, specify: _________________________ C. Food Storage/Cooking Facilities a. Storage: ( ) refrigerator ( ) cabinet ( ) basket ( ) table ( ) covered ( ) uncovered b. Cooking facility: ( ) electric stove ( ) gas stove ( ) firewood/charcoal c. sanitary condition: __________________________ D. Garbage/Waste Disposal: a. Refuse and garbage: 1. Storage: ( ) Container: ( ) plastic bag ( ) none ( ) covered ( ) open 2. Waste Segregation: ( ) Practiced ( ) Not practiced 2.1 If practiced, method of disposal: a. biodegradable ( ) hog-feeding ( ) open dumping ( ) burial in pit ( ) collected ( ) composting

b. Non-biodegradable ( ) recycle

( ) reuse

( ) collected

( ) others:___?

2.2 Reason for practicing: ( ) environmentally friendly ( ) barangay ordinance which is strictly Monitored ( ) use for business ( ) others, specify ______

2.3 If not practiced, method of disposal: ( ) open dumping ( ) burial in pit ( ) open burning ( ) garbage collection ( ) others specify: _________________ 2.4 Reason for not practicing: ( ) not aware of effects ( ) no time to do it ( ) long-time practice of family ( ) not a barangay ordinance/ not strictly monitored c. 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 ( ) others, specify: ___________________________ 3. Location from source of water: ( ) less than 20 ft ( ) 20 ft beyond 4. sanitary condition: ___________________________ d. Drainage System: ( ) open drainage Condition: ( ) flowing

( ) blind drainage ( ) stagnant

( ) none

E. Presence of Animals that are rabies carriers a. Animals raised Kind Number Where Kept Inside Outside

With regular Vaccination

Without Vaccination

b. Practices/ measures done to control insects/vectors of diseases: ( ) fumigation ( ) insecticides ( ) setting traps ( ) cleaning the yard ( ) none c. Presence of breeding sites: ( ) none ( ) with ***For observation:

F. Housing Congestion: ( ) Yes ( ) No G. Presence of Industrial establishments/ factory/ies:

( ) Yes

( ) No

Name

Age

Age started smoking

Reason

III. Health and Illness Pattern 1. Lifestyle Practices (according to family) A. Hygiene Practice 1. Taking bath regularly 2. Brushing the teeth 3. Handwashing before and after eating 4. Nail cutting 5. Use of hygienic products 6. Ear cleaning 7. Regular change of clothes B. Rest and Sleep 1. sleeps at least 8 hours per day 2. takes nap / rest period with in the day Not Practiced

G. Use of prohibited / dangerous drugs Name Age Age started using

( ) Yes Reason

( ) No

H. Drinks Alcoholic beverages: Name Age Age started drinking Frequency Reason

2. Nutritional Status a. Anthropometric Data ( especially for vulnerable and at-risk members) C. Exercise Name 1. perform regular exercise every day 2.Performs recreational activities D. Health Promotion Activities 1. has regular medical check up ( once a year) 2. has regular dental check up ( every 6 months) E. Use of Safety Precaution 1. use safety devices when necessary e.g. helmet, safety belts F. Is there a member of family who is cigarette smoker? ( ) Yes ( ) No WC in cm. HC in cm. WHR (WC/HC Remarks MUAC (recorded to the nearest 0.1cm) Remarks Age in month s/ years Wt. in Kg. Ht. in meters BMI Remarks

C. Second choice: ( ) meat only ( ) fish only D. Number of servings: ()1 ( ) 2-3 Legend for Indices of Nutritional Status: Weight for Age (WFA) 0 83 months compared with (IRS) adopted for Filipinos N Normal (within 2SD of median IRS UW - Underweight (< -2SD of Median IRS OW overweight (>+ 2SD of Median IRS 9 19 years Adults (WHO,2000) N Normal: P15-P85 U underweight: < 18.5 MU mild underweight:P3 - < P85 N normal: 18.5 24.9 U Underweight: <P3 Ow overweight: 24.0 29.9 O overweight: >P85 Ob obese > 30 Risk assessment measures for Obesity WC - > 90cm (M) Central Obesity: > 80cm (F) WHR: (M) - =/> 1.0cm (F) 0.85 cm b. dietary history 24 hour food recall DATE NOTED TIME OF THE DAY FOODS TAKEN

( ) vegetable only

( ) mixed ( ) others, specify:______

( ) 4-5 and above

E. Reason for choices: ( ) think its healthy ( ) own preference ( ) affordable ( ) personal belief/practice ( ) health condition F. Reason for not choosing other options: ( ) not healthy ( ) own preference ( ) not affordable ( ) personal; belief/practice ( ) health condition G. From the above response, how frequent is the intake? ( ) everyday ( ) every 3 day ( ) once a week ( ) others, specify: ___________ H. How is food prepared for mealtime? ( ) prepared at home ( ) bought outside I. How often? ( ) everyday ( ) every 3 day ( ) once a week ( ) others, specify: ___________ J. If bought outside, is it from the: ( ) restaurant/fast food ( ) carinderia ( ) food cart, ex. KFC, pusit, provens K. Reason for the above option: ( ) convenience ( ) cheaper ( ) healthy ( ) variety of choices ( ) others, specify:_ L. Takes / eat canned / preserved food. Ex. Lucky me, maling, ( ) everyday ( ) every other day ( ) every week ( ) sometimes ( ) never M. Takes / eat fried foods ( ) everyday ( ) every other day ( ) every week ( ) sometimes ( ) never N. Drinks carbonated beverages ( ) occasionally ( ) weekly ( ) everyday 3 .Beliefs and Practices (per family) I. Person/nel mostly consulted in times of sickness/illness ( ) doctor ( ) nurse ( ) midwife ( ) hilot ( ) albularyo ( ) faith healer ( ) elderly 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 Medication/treatment taken in times of sickness/illness ( ) prescribed by doctor ( ) over the counter /self- medication ( ) herbals ( ) others, specify: _______________

BREAKFAST

LUNCH

II.

III. DINNER

4.Community health programs( observation / key informant) Foods usually/most taken A. First choice: ( ) meat only ( ) fish only ( ) vegetable only ( ) mixed ( ) others, specify: ______ B. Number of servings: ()1 ( ) 2-3 ( ) 4-5 and above A. What are the health services available in the barangay health center? ( observation / key informant)

B. Immunization record (0-12months) put a check for all immunization received.

( ) religious belief ( ) others, specify_______

( ) influence by others

Name of child

Age in mos

Se x

BCG

DPT 1

DPT 2

DPT 3

Hepa B1

( ) non-acceptor

2. Methods used: 2. Health Indicators A. Morbidity Hep B2 Hep B3 OPV 1 OPV 2 OPV 3 Measles complete accdg to age Incom plete Accdg To age FIC Name Age

Reason: ( ) bad for health of family ( ) personal belief ( ) religious belief ( ) influence by others ( ) others, specify__________ ( ) natural ( ) artificial ( ) permanent

(January December 20--) Gender Cause Intervention With Without Result

B. Antenatal Registration NAME AOG PRENATAL CHECK-UP TETANUS TOXOID VACCINATION WITH WITH OUT

B. Mortality (January December 20--) Pls specify if infant, pregnant...) Name Age Gender Cause of death

WITH REGULAR NOT REGULAR

WITH OUT

C. History/Presence of Non Communicable Disease in the Family ( e.g. heart dse, Hpn, DM, Cancer, Kidney Dse etc.) Name Age Gender NCD

C. Family Planning 1. Family Planning: ( ) acceptor Reason: ( )good for health of family ( ) personal belief

A. health budget and expenditures B. availability of supplies, equipment

D. History/Presence of Communicable Disease in the Family (e.g. chicken pox, measles, dengue, TB etc.) Name Age Gender CD

V. Political / Leadership Patterns 1. Recognized leader Formal/elected: ( ) captain ( ) Kagawad Non formal: ( ) elderly ( ) BHW ( ) influential person ( ) religious leader ( ) neighbour 2. Conditions / events/ issues that cause social conflicts/upheavals within the community: ( ) gossip ( ) drugs ( ) alcohol drinking ( ) personal / familial conflict ( ) riot ( ) others: ______

E. Blood Pressure Record for ages 35 above Name Age Gender Bp

3. Practices / approaches which are effective in setting issues and concerns within the community: ( ) settlement among involved parties ( ) brgy hearing ( ) endorsed to local police ) others: _____

d. Awareness of health services offered by the BHC / RHU : ( ) aware ( ) unaware IV. Health Resource ( Key Informant Interview) 1. Manpower Resources A. categories of health manpower available B. geographical distribution C. number of physician, nurse , midwife and other members of RHU team per population D. existing manpower development / policies E. schedule of consultations at the BHC: RHU Physicians: ________ RHU Nurse: ____________ BHC Midwife: __________

2. Material Resources