Number of family Sex M Age Infancy (0-12 mos) Toddler (1-3 y/o) Pre schooler (4-6 y/o) School

age (7-12 y/o) Civil Status C S M Religion RC P INC BAC Education P EL EG HL HG V Place of Origin NCR CL NL Length of Residence 1-10 years 11- 20 years 21- 30 years 31- 40 years 41 - 50 years Type of Work E RF RP C Place of Work: Location I IM/C O OFW Type of family: Nuclear Dyad Matriarchal Matricentric Patrilocal

Adolescent (13-19 y/o) Young adult (20-25 y/o) Adult (25-60 y/o) Old age (60 above)

Priorities and Expenditure 1 2 Food Clothing Education Health Utilities Recreation Savings Decision maker Father Mother Both Adequacy of family income Adequate

MS W Wr

Family Others

Not adequate

JW M others

SC CL CG PG None

SL V M

51- 60 years 61 - 70 years 71 - 80 years 81 - 90 years 91 - 100 years

Cultural orientation regarding illness Believes that illness is caused by physiologic factors Believes that illness is caused by supernatural phenomenon Believes that illness is a punishment from God Believes that illness is caused by other person Believes that illness is caused by change in weather others 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 Health can be restored by health personnel Cultural practices Always practices local cultural practices about health matters Sometimes practices local cultural practices about health matters Does not practice local cultural practices about health matters Cultural practices Always practices local cultural practices about health matters Sometimes practices local cultural practices about health matters Does not practice local cultural practices about health matters Community involvement Actively joins fiesta, religious procession, local cultural practices Does not actively join Home Ownership Construction materials used No. of rooms used for sleeping Adequacy of space Lighting facility Adequacy of lighting Ventilation General Sanitary condition

CW CE S UE

Place OF FC EL

Owned Rented Light Mixed 1 2 Adequate Electricity kerosene Adequate Adequate Poor Fair

Rent-free Least to own Strong 3 4 Inadequate Others Inadequate Inadequate Good Excellent

Extended Homosexual Patriarchal Patricentric Matrilocal

Single parent Cohabiting/common-law Egalitarian Drinking Water Supply Ownership Private Public Source Deep well Local water district Commercial Portability yes No Storage None Large covered container with faucet Large uncovered container without faucet others Food Storage / Cooking facilities Storage Refrigerator Cabinet Basket Table Cooking Electric stove Facility Gas stove Firewood/charcoal Sanitary Poor condition Fair Garbage/Waste disposal Storage Container Plastic bag None Waste Practice Segregation Not practice Biodegradable Hog feeding Open dumping Burial in pit Non Recycle

Neolocal

Dialect frequently used: Tagalog

Covered Uncovered

Monthly family income: Less than 5,000 5,000-10,000 10,001-15,000

15,001-20,000 20,001-25,000 25,001-30,000

Financial Source of Family Expenditure Employment Business Pension Help from relative/friends Others Monthly Family Expenditure: Less than 5,000 5,000-10,000 10,001-15,000

Good Excellent

Covered Open

15,001-20,000 20,001-25,000 25,001-30,000

Collected Composting

Biodegradable Reason for practicing

If not practiced, method of disposal Reason for not practicing

Reuse collected Environmental friendly Barangay ordinance which is strictly monitored Use for business Others Open dumping Garbage collection Burial in pit Open burning Others Not aware of effects Long time practice of family No time to do it Not a Barangay ordinance / not strictly monitored

24 Hours Food Recall Breakfast

Lunch

Dinner

Toilet facilities Ownershi Owned p Shared / public Type Ballot system Open pit privy Closed pit privy Overhung latrine Location from source of water Sanitary condition Less than 20 ft

none Bored hole latrine Antipolo type Water sealed others 20 ft beyond

Poor Fair

Good Excellent

Drainage system Type Condition

Open drainage Flowing

Blind drainage Stagnant

none

Animal raised Kind Number

Inside

Outside

With vaccine

Without vaccine

Practices done to control insect/ vectors diseases Fumigation Cleaning the yard Insecticides none Setting traps Presence of breeding sites None With Housing congestion Yes No Presence of industrial establishments/factory/ies Yes no 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 Rest and Sleep 1. Sleeps at least 8 hrs per day 2. Takes nap/ rest period with in the day Exercise 1. Perform regular exercise every day 2. Perform recreational activities Health promotion activities 1. has regular medical check up 2. has regular dental check up Use of safety precaution 1. use safety devices when necessary Yes Cigarette smoker Use prohibited/ dangerous drugs Drinks Alcoholic beverages Nutritional status Wt for Age 0-83 months N UW OW No Not practiced

Foods usually/mostly taken First choice Meat only Fish only Vegetables No. of servings 1 2-3 2nd choice Meat only Fish only Vegetables No. of servings 1 2-3 Reason for Thinks its healthy choice Own preference Affordable Personal; beliefs/ practice Health condition Reason for not Not healthy choosing other Own preference options Not Affordable Personal; beliefs/ practice Health condition How frequent is Every day the intake Every 3 day How food is Prepared at home prepared Brought outside How often Every day Every 3 day If brought Restaurant/ fast food outside, is it Carinderia from the Food cart Reason for Convenience above option Cheaper Healthy Takes Every day preserved food Every other day Every week Sometimes Never Takes fried Every day foods Every other day Every week Sometimes Never Drinks Occasionally carbonated Weekly beverages everyday

mixed Others 4-5 & above mixed Others 4-5 & above

Once a wk Others

Once a wk Others

Variety of Choices Others

Beliefs and practices Person mostly Doctor Albularyo consulted in Nurse Faith healer times of Midwife elderly sickness Hilot Measures taken Consult a private health worker in times of Consult a rural health team sickness See a known community healer Self medicated None Medication Prescribed by doctor taken in times Over the counter/ self medication of sickness Herbals Others Family planning Acceptor Good for health f family Religious belief Personal belief Influence by others others Natural Methods used Artificial Permanent BP Normal 100/80 Pre hypertension 120/80 Hypertension 130/90 & above

Non acceptor bad for health f family Religious belief Personal belief Influence by others others

9-19 years N MU U O U N Ow Ob

Adults