Saint Paul University Philippines • Diagnosed by a practitioner?

• Yes: / • No: ___

Tuguegarao City, Cagayan Valley 3500
I. Number of Pregnant Women:
DATA BASELINE SURVEY FORM •Age < 15 __ •Age 15 – 19: ___ • Age 20 – 24: ____
• Age 25 – 29: ___ • Age 30 above: ____
Zone:1 Household No: 464 • Others, specify: ______
Date of Assessment: February 28 2023
Name of Assessor: KIMBERLY NICOLE LUMAUIG J. Housing:
Head of the Family: JOEL LUMAUIG *Age of House:
•0-5 __ • 6-10 __ • 11-15__ • above 15 years /
A. Family Size:
Number of Adults: 1 Male 3 Female * Materials used:
Number of Children: 0 Male 3 Female • Concrete / • Wood __ • Bamboo __ • Mixed

B. Marital Status: * Number of floors:

• Single: ___ Male __ Female • One • Two / • Three __ • Four __
• Married: /
• Widow: • Widower: ___ * Lighting Facility:
• Separated: • Electric Bulb / • Candles __ • Gas Lamps __

C. Educational Attainment: * General State of Repair:

• Elementary Undergraduate: _ • Roof __ • Floor __ • Walls __ • Ladder __ • Window
• Elementary Graduate: __ • Door __
• Highschool Undergraduate: ___ • Foundation __ • Roof Braces __ • Rooms __ • Sink
• Highschool Graduate: ___ __
• College Undergraduate: __ • Kitchen __ • Toilet __ • Others:
• College Graduate: __________________
• TechVoc Course Graduate: /
K. Hangouts:
D. Occupation: • Store _/ • Waiting Shade __ • Court __ • Yards _/•
• Farmer: ____ • Carpenter: ____ • Housewife: ____ House / •Others: __________________
• Driver: • OFW: ____
• Others, specify: BUSSINESS OWNER L. Animals:
_________________ • Dogs: / • Cats:/ • Pig: / • Chicken: /
_________________ • Duck: ___ • Bird: ___ • Goat: ___ • Carabao: ___
• Cow: ___ • Others: RELATIVES
E. Religion:
• Roman Catholic: / • Baptist: _____ M. Water (drinking):
• Born Again: ____ • Others, specify __________ * Source: • Faucet • Deep __ •Well __ • Pump Well
__
F. Types of Family: • Others, specify: MINERAL WATER
• Dyad __ • Nuclear;/ • Extended __
• Blended _ • Single Parent * Ownership: • owned / • shared __

G. Authority:
a. Decision Making: * Storage: • Refrigerated • Not refrigerated __
• Patriarchal • Matriarchal __ • Egalitarian / • Covered __ • Not covered __
b. Child Discipline:
• Patriarchal __ • Matriarchal • Egalitarian / M. Water (general usage):
c. Healthcare Decisions:
• Patriarchal __ • Matriarchal • Egalitarian / * Source: • Faucet ✔️• Deep Well __ • Pump Well __
d. Financial Management: • Others, specify: ______________
• Patriarchal • Matriarchal __ • Egalitarian /
* Storage: • Refrigerated / • Not refrigerated __
H. Diseases: • Covered / • Not covered __
• Head ache: ___ • Colds: ___ • Cough: ___ • Fever: • Drum / • Jags __ • Bottles __ • Pail __ • Jar
___ • Others, specify: __________ __
• Hypertension: / • TB: ___ • DM: ___ * Usage: • Bathing / • Cooking / • Laundry /
• Others, specify: HORMONAL IMBALANCE
N. Food: * Source:
* Cooking facility: • Firewood / • Gas stove / • • Farming __ •Employed / • Self- employed /
Charcoal __• Electric Stove / • Others: ________ • Pension __ • Others: _____________________
* Storage: • Refrigerated / • Not refrigerated __
• Covered __ • Not covered __ * Monthly income:
* Usual Number of Meals per day: 5 • 0 – 500 ++ • 501 – 1000 __
* Usual Composition: • 1001 – 2000 __ • 2001 – 3000 __
• Vegetable / • Fish / • Chicken / • Meat /• Fruits / •
Rice / • 3001 – 4000 __ • 4001 – 5000 ✔️ • 5001 –
•pork /•beef /•others SEA FOODS above /

O. Exercise: * Expenditure: • Clothing / • Education / • Food / •

• Yes: / • No: _____ Farm __
* Types: • Housing / • Medicine /• Others: ______________
• Jogging: __ • Walking: / • Work: /
• Biking: ___ • Stretching: ___ • Others: __________ * Products: • Rice • Corn • Vegetables __
• Poultry__ • Others: ____________
* Land ownership: • Tenant __ • Owned
P. Vices:
• Smoking: ______ W. Other Information:
• Drinking Alcohol: / * Protective Services Available:
• Police/ • Army / • Tanod / •security guard __
Q. Leisure and Recreation:
• Chatting: /• Listening to radio: / • Sports: ___ * Security Facilities Available:
• Sleeping: / • Walking / • Watching TV: / • Streetlights/• Road humps / • CCTV / • Others:
• Playing cards: ___ • Others: _________________ __________

R. Toilet: * Social Facilities Available:

* Ownership: • owned / • shared __ • Courts / • Waiting shades / • Others: ____________
* Type: • Flush / • Pail system
• Open pit __ • Close pit __ • Water sealed * Healthcare Facilities Available:
__ • Botika / • Health Center / • Others: ____________
* Distance: • 2 – 3M / • 4 – 5M • 6 – 7M
• 8 – 9M • 9 – 10M • 11 – above * Healthcare Providers Present:
• Nurse / • Doctors / • Midwives /
S. Garbage: • Trained Hilot / • Albularyo /• Health Education /
* Container used: • Trashcan / • Plastic __ • Sack • Check – ups /
__ • Others: ________________________________
• Box __ • Pail __ •
Hole __ * Level of Satisfaction:
* Method: • Burning __ • Composting / • Open • Very Satisfied / • Satisfied • Not Satisfied __
dumping __
* Waste Segregation: • Yes / • No __ * Frequency of Visiting Healthcare Facilities:
• Once __ • Twice __ • Thrice __ • As needed /
T. Drainage System:
* Type of Drainage: • Open __ • Close / * Name of Healthcare Provider/s:
* Household drainage: • Open __ • Close /• None __ 1. KRYSTAL CULLILI
2. STEPHANIE FERER
U. Transportation: 3. _FAYE UBAUNDO
• Jeepney __ • Truck __ • Motorcycle / • Tractor * Reasons for Visiting Health Centers:
__• Tricycle / • Van __ • Other: CAR, AIRPLANE, • Health Education / • Check – up / • Medicine /
BARKO • Feeding Program __ • Others: _________________

V. Income: * Name of Organizations:

* Who earns? 1. _______________________________________
• Mother • Father • Both Parents / 2. _______________________________________
• Children __ • All __ 3. _______________________________________
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