I.

Demographic Variables
Age
0 - 18 mos
18mos 3yrs
3 6 yrs
6 12 yrs
12- 20 yrs
20 25 yrs
25 65 yrs
65 yrs and
above
Educational Attainment
Not Yet
Studying
Out of
School
Elementary

Sex
Male
Female

Religion
Catholic
Born Again
7th day
Adventist
INC
Others

Civil Status
Single
Married
Separated
Widowed

Based in Internal Organization &

Membership
Nuclear
Extended

Based on Authority
Patriarchal
Matriarchal
Egalitarian
Matricentric

Place of Origin
Luzon
Visayas
Mindanao

High
School
College
Based on Place of Resident
Patrilocal
Matrilocal
Bilocal
Neolocal
Avunculocal

II. Socio-Economic and Cultural Variables

Means of Communication
Modes of Transportation
Landline
Tricycle
Mobile
Jeepney
Phone
Pedicab
E-Mail
Bus
Postal Mail
Other
Others
Economic Indicators
Occupation

Type of Neighborhood
Congested
Squatter
Type of House
Concrete
Makeshift
Mixed w/
Cement
Mixed w/
Wood
Other
Cooking Environment
Backyard
Sidewalk
Inside
Other

Total Monthly Income

No Income
1-999
1,000-2,999
3,000-4,999
5,000-6,999
7,000 above
Lot Ownership
Owned
Rented
Squatting
Ventilation
With
Without

Cooking Facility
Collected
Burying
Open
Dumping
Burning
Other

Health Hazards
(Housing Conditions)
Congestion
Exposure to
Chemicals
Fire Hazard
Electric
Wires
Other
Industry Present in the Community:

House Ownership
Owned
Rented
Free
Lighting Facilities
W/
Electricity
W/O
Electricity

Water Source
MWSS
Deep Well
Artesian
Owned
Shared

Type of Toilet
Flush Type
Pit Privy
Pail
System
Overhang
Latrine
Other
Owned
Shared
Race

Garbage Disposal
Collected
Buried
Open
Dumping
Burned
Other

Drainage System
Open
Closed
None

Ethnicity

Dialect

Birth Attendant
Hilot
Midwife
MD
No Child
Other

Herbal Medicine
Taheebo
Sambong
Lagundi
Oregano
Bayabas
Other

Family Planning
Pills
Condom
Surgery
Withdrawal
None
Other

Past Illness

Cause of Death

III. Health and Illness Patterns

Present Illness

IV Health Resources
Community Resources
Barangay Hall
Health Center
Market
Church
School
Park
Familys Source of Health Fund
Income
Govt
Assistance
Private Health
Agency
None
Other
V. Political/ Leadership Patterns
Relationship w/ Barangay Officials
Cause of Conflict
Good
Fair
Poor

Health Maintenance Budget

No Income
1-999
1,000-2,999
3,000-4,999
5,000-6,999
7,000 above

Programs