Appendices

Appendix A.
TOOL 1

I. GENERAL DATA

Head of the Family: ___________________________________________

Address: Province: ___________________________________________

Municipality/City: ___________________________________________

Barangay: ___________________________________________

Purok: ___________________________________________

Household No: ___________________________________________

II. RESIDENCE STATUS

 Lot Ownership ( ) Owned ( ) Rented ( ) Others, Please Specify: _____________

House Ownership ( ) Owned ( ) Rented ( ) Others, Please Specify: _____________

Year of Residency: ___________________________________________

Place of Origin: ___________________________________________

III. FAMILY CENSUS

1. Household members (Include the head of the family)

Relationship to Civil
Ag Se Educational
NAME the Head of the Statu Occupation Religion
e x Attainment
Family s

2. Total Household Monthly Income: ____________________________________

3. Family Structure: ____________________________________
4. Family member heading on decision making: ____________________________________

IV. HEALTH STATUS AND PRACTICES

 1. Herido familial disease existing in the family: ____________________________________
___________________________________________________________________________________

2. Common illness encountered by members of the family:____________________________

___________________________________________________________________________________

If illness occurred at home, what do you do or to whom do you consult first?

( ) Self-medicate or OTC drug ( ) Visit midwife/health center

( ) See a quack doctor ( ) Use herbal medication

( ) Consult a doctor ( ) Therapeutic Massage (Hilot)

( ) Other, Please specify: ______________________________________________________

3. Primary source of Health Care:

( ) Health Center ( ) Hospital ( ) Clinic

( ) Other, Please specify: ______________________________________________________

4. Availability/Utilization of health services ( ) Yes ( ) No

If No, specify reason: __________________________________________________________

5. Health personnel feedback: ( ) Friendly ( ) Unfriendly

V. IMMUNIZATION PROFILE (for children 0-2 years)

1. Are you aware of immunization program? ( ) Yes ( ) No

If No, specify reasons: _________________________________________________________

2. Where did you get the information?

( ) BHW/Health Center
( ) Hospital
( ) Government offices: Name: ____________________________________
( ) Private Agencies: Name: ____________________________________
( ) Media:
[ ] TV [ ] Radio [ ] Press
[ ] Others, please specify: _______________________________________
3. Are your children immunized? (ages 0 2 )
( ) Yes ( ) No If no, specify reasons? ____________________________
If yes, fill up the chart below:

NAME OF A DATES OF IMMUNIZATION RECEIVED REMARKS

CHILD
 C-Complete

INC-Incomplete

G NI-Not immunized

HEP B 1

HEP B 2

HEP B 3
OPV 1

OPV 2

OPV 3
DPT 1

DPT 2

DPT 3
BCG

MSL
4. Place where the child obtain immunization inoculation?
( ) Barangay Health Center ( ) Clinic ( ) Hospital
( ) Others, Please specify _____________________________________________________
5. Do you know the diseases a child would acquire if not immunized?
( ) Yes ( ) No
If yes, specify the disease _____________________________________________________

6. Do you know the symptoms and side effects after the child get immunized?
( ) Yes ( ) No
If yes, what measures taken to ease the effect of the vaccines?
______________________________________________________________________________________
________________________________________________________________________

7. Did you pay for the vaccines?

( ) Yes ( ) No

VI. NUTRITION
A. Children 0-5 years
Name of Child Age/Months Weight Height Birth date Nutritional
 Status

1. Food given to children 0-2 years:

( ) breast milk ( ) milk formula ( ) mixed feeding (BF +)

Others, please specify: _________________________________________________

If giving infant formula, specify type: ___________________________________

2. How they clean their feeding bottle? _______________________________________

___________________________________________________________________________

3. What supplementary food do they give to the child?

___________________________________________________________________________

4. Does Vitamin A given to children of 12-59 months?

( ) Yes ( ) No

If yes, when was the last vitamin given? ________________________________

B. Food Preparation
1. How does the family prepare their food?

Well Uncooked/ Half- Other

Types Of Food
Cooked Raw Cooked Preparation

1. Rice
2. Corn
3. Meat
4. Fish
5. Vegetables
6. Fruits
7. Others
 2. Food storage and handling (for leftovers)
( ) Covered ( ) Given to animals

( ) Not covered( ) Others, Please specify

3. Cooking facilities
( ) Fire wood ( ) Charcoal ( ) LPG fueled

( ) Kerosene/stove ( ) Electric stove

( ) Others, Please specify: ______________________________________________

4. Type of salt used by the household?

( ) Iodized salt ( ) Ordinary salt

VII. PREGNANCY

1. Information on Pregnancy
Last Number of
Name of Age of Tetanus Number of
Menstrual Prenatal
Pregnant Pregnancy Toxoid Pregnancy
Period Visit
 2. Did you experience miscarriage?
( ) Yes ( ) No
If yes, specify the reason?
_______________________________________________________________________________
_________________________________________________________________

3. Where do you go for prenatal?

( ) Health Center ( ) Therapist/Hilot

( ) Doctors Clinic ( ) Hospital

( ) Others, Please specify: ________________________

4. Where do you plan to/usually deliver?

( ) Lying In/Birthing Home

( ) Municipal Health Office/City Health Office

( ) Hospital

( ) Home

( ) Others, please specify: ______________________________________________

VIII. FAMILY PLANNING

1. Were you informed about family planning? ( ) Yes ( ) No

If No, Why? ____________________________________________________________
2. Where did you get the information?
( ) BHW/Health Center
( ) Hospital
( ) Government offices: Name: ____________________________________
( ) Private Agencies: Name: ____________________________________
( ) Media:
[ ] TV [ ] Radio [ ] Press
( ) Others, please specify: ______________________________________________

3. What kind of Family planning method did you use?

( ) IUD ( ) Pills
( ) Condom ( ) Ligation
( ) Vasectomy ( ) Injectables
( ) Calendar Method ( ) Lactation Amenorrhea Method
( ) Basal Body Temperature ( ) Withdrawal
( ) Others, please specify: ______________________________________________
 4. How long have you been using the family planning method?
________________________________________________________________________
5. Was there any significant effect you felt as you used this kind of method?
( ) Yes ( ) No
If yes, please specify below:
__________________________________ __________________________________
__________________________________ __________________________________
__________________________________ __________________________________

IX. HOME CONDITIONS AND SURROUNDINGS

A. Housing Factors
1. House condition ( ) Very good ( ) Good ( ) Poor
2. Type of house ( ) Wood ( ) Concrete
( ) Mixed ( ) Bamboo
( ) Others, please specify: ________________________
3. Lighting condition ( ) Very good ( ) Good ( ) Poor
What do you use? ( ) Light bulb ( ) Torch ( ) Lamp
( ) Others, please specify: ________________________
4. Ventilation ( ) Very good ( ) Good ( ) Poor

B. Water Facility
1. Source of water Supply
( ) Spring ( ) Water district
( ) Water well/closed ( ) Open/Artesian
( ) Others, please specify: ______________________________________________
2. Water source ownership
( ) Shared ( ) Owned ( ) provided by the government
( ) Others, please specify: _______________________________________
3. Water storage
( ) Covered ( ) Uncovered ( ) Faucet
( ) Owned ( ) Shared
4. Have you noticed any effect that may have caused illness in drinking water?
( ) Yes ( ) No
If yes, please specify: __________________________________________________

5. Distance of comfort room from the water source: _______________________

C. Plants/Vegetation
1. Plants in the surrounding
( ) Vegetable ( ) Herbal ( ) Ornamental
2. List kinds of vegetable plant found in the surrounding
_______________________________________________________________________________
_________________________________________________________________
3. Information on the 10 herbal plants approved by DOH
( ) Yes ( ) No
 If yes, please fill up the table below:

Herbal Plant Indication Method of Use

X. WASTE MANAGEMENT

A. Garbage
1. Garbage disposal
( ) Garbage can
[ ] Covered [ ] Uncovered
( ) Burned
( ) Dumped
( ) Collected, please specify frequency: _________________________________
( ) Others, please specify: ______________________________________________
2. Waste segregation method
( ) Yes ( ) No

If yes, specify method: _________________________________________________

If no, please specify reasons: ___________________________________________

3. Where did you get the information on waste segregation?

( ) BHW/Health Center
( ) Government Agency Name: ____________________________________
( ) Private Agency Name: ____________________________________
( ) Media:
[ ] TV [ ] Radio [ ] Press
( ) Others, please specify: ______________________________________________
4. Do you recycle garbage?
( ) Yes ( ) No

If yes, specify how: _____________________________________________________

 5. Where did you get the information on waste recycling?
( ) BHW/Health Center
( ) Government Agency Name: ____________________________________
( ) Private Agency Name: ____________________________________
( ) Media:
[ ] TV [ ] Radio [ ] Press
( ) Others, please specify: ______________________________________________

B. Toilet
1. Toilet ownership
( ) Shared ( ) Owned
( ) Others, please specify: ______________________________________________
2. Type of toilet
( ) Antipolo ( ) Water-sealed
( ) Cat hole ( ) Flying Saucer
( ) Others, please specify: ______________________________________________
C. Premises indication

1. Drainage (canal)
( ) Present ( ) None
( ) Covered ( ) Uncovered
( ) Others, please specify: ______________________________________________
2. Frequency of cleaning
( ) Daily ( ) Monthly
( ) weekly ( ) Yearly
( ) Others, please specify: ____________________________________________
3. Breeding places
( ) Present ( ) None
( ) If present, please specify: ___________________________________________
4. Methods use to control breeding places
( ) Fogging ( ) Mosquito net
( ) Insecticides ( ) None
( ) Others, please specify: ______________________________________________
5. Frequency of method used
( ) Daily ( ) Monthly
( ) weekly ( ) Yearly
( ) Others, please specify: ____________________________________________

XI. HEALTH INSURANCE

1. Information about Health Insurance

( ) Yes ( ) No
If yes, where the information obtained?
( ) BHW/Health Center
( ) Government Agency Name: ____________________________________
( ) Private Agency Name: ____________________________________
( ) Media:
[ ] TV [ ] Radio [ ] Press
 ( ) Others, please specify: ______________________________________________
2. Do they have Health Insurance?
( ) Yes ( ) No
If No, please specify reasons and their plan to obtain health insurance:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Note: To secure MORTALITY and MORBIDITY DATA, please refer to BARANGAY HEALTH
CENTER
Appendix B.