III.

Health & Medical History

1. Present Illness:
Name
Tomasa
Concepcion
Susan Espiritu

Chief
Complaint
Sumasakit ang
kasu-kasuan
Sumasakit ang
Tuhod

Medical Attendance
With
Without

Remarks

Medical Attendance
With
Without

Remarks

2. Past Illness: (for the last 5 years)

Name
Danilo
Villapando

Chief
Complaint
Seen with
small masses
on his thyroid

Underwent
Total
Thyroidectomy

3. Immunization Status:
No children at home ages below 5 years old

4. Sources of Medical Care

a. Health Center Calabash Health Center
b. Hospital University of Santo Tomas Hospital
c. Private Physician Dr. Melchor Chan; Cardilogist: Dr. Francis Purino;
Endo: Dr. Elaine Cunanan
5. Nutritional Assessment
No children being breastfed nor formula-fed.

IV. Environmental Factors

A. Home
1. Ownership
( ) owned
( ) rented
(
2. Construction materials used:
( ) Light
( ) Mixed
(
3. State of Repair
( ) good
( ) fair
(
4. Overcrowding
( ) with
( ) without
5. Privacy
( ) with
( ) without
6. Lighting
( ) with electrivity
( ) without electricity
7. Venitlation
( ) satisfactory
( ) fair
(

Calculations:

) rent-free
) Strong
) dilapidated

) poor

Total Window Opening:

Length: 1.4 m

Length: 8 m

Width: 1.1 m

Width: 6 m

2
1.4 m

2
48 m

3 windows
4.2 m

1 floor
48 m

TSR
Adult: 10 y/o and above = 3 sqm
3 persons x 3 sqm = 9 m
TSA > TSR
48 m2 >9 m2

Total Space Area

B. Environment
1. Drinking Supply
a. Source:
( ) MWSS
( ) Artesian
b. Ownership:
( ) owned
2. Toilet Facility
a. Type of Toilet
( ) none
( ) overhung latrine
( ) open pit privy
( ) closed pit privy
( ) bored-hole latrine

( ) Open Dug well

( ) Others, Specify: _________
( ) shared

(
(
(
(
(

) pail system
) Antipolo
) water-sealed latrine
) flush type
) other, specify: _________

Distance from house: 3 meters

b. Ownership:
( ) owned
c. Sanitary Condition
( ) Sanitary
3. Refuse Disposal
( ) hog feeding
( ) open dumping
( ) burial in pit
( ) composting
4. Drainage System
( ) hog feeding

5. Domestic Animals

( ) shared
( ) unsanitary
( ) open burning
( ) garbage collection
( ) other, specify: _________

( ) open burning

( ) none

Kind
Cat

Number
2

With Pens
0

6. Insect & Vermin Control

a. Home
( ) mechanical
( ) chemical
( ) others, specify, ________

Without Pens
2

( ) biological