BARANGAY Employed ( ) Unemployed ( ) Self-employed ( )

HH. NO. Monthly Income

DATE OF SURVEY Below P1,000 ( )
RESPONDENT P2,000-P3,000 ( )
INTERVIEWER P3,000-P4,000 ( )
I. FAMILY DATA More than P5,000 ( )
A. Head of the Family ________________________________ Age ________________
B. Name of Spouse __________________________________ Age ________________ B. Monthly Expenditures
C. Address _________________________________________ Tel. No. _____________ 1. Food
D. Education Attainment Below P20 ( )
I. Husband ____________________________________ P30-P50 ( )
II. Wife _______________________________________ More than P50 ( )
E. Length of Residency _______________________________ 2. Clothing Number of times of buying
Ethnic Origin _____________________________________ Once a year ( )
F. Family Twice a year ( )
Nuclear ( ) Extended ( ) Thrice a year ( )
G. Religion _________________________________________ Four times or more ( )
H. No. Of Children ___________________________________ 3. Housing
Water ( )
Telephone ( )
Name Age Sex Status Education Occupation Electricity ( )
4. Schooling
Public ( )
Private ( )
Others ________________

III. HOUSING AND ENVIRONMENTAL CONDITION

A. Type of Housing
Concrete ( )
Mixed ( )
Wood ( )
Makeshift ( )
Others ___________________________
Is the house owned? ______________________________
Ventilation:
Poor ( )
Good ( )
Lighting:
Adequate ( )
II. SOCIO-ECONOMIC DATE Inadequate ( )
A. Source of Income Surroundings:
Occupation Clean ( )
Husband ______________________ Dirty ( )
Wife _________________________
B. Source of Water Supply G. Presence of animals
Artesian Well ( ) Dogs( )
NAWASA ( ) Pigs ( )
Deep Well ( ) Cats ( )
Others ( ) Others ___________________________

C. Storage of dringking Water H. Backyard Gardening

Refrigerated ( ) Vegetables ( )
Uncovered ( ) Fruit bearing ( )
Covered ( ) Herbal ( )
Others ___________________________
Containers used
Plastic ( ) IV. COMMUNITY RESOURCES
Bottles ( ) Health Center:
Jars ( ) School ( )
Others _______________________ Park ( )
Barangay hall ( )
D. Toilet Facilities Church ( )
Sanitary: Market ( )
Flush ( ) Indigenous Health Workers:
Owned ( ) Trained “Hilot” ( )
Pit privy ( ) “Hebularyo” ( )
Shared ( ) BHW ( )
Others ___________________________ Untrained “Hilot" ( )

Unsanitary: V. NUTRITION
“Balot” system ( ) A. Food Preference:
Others ___________________________ Fish ( )
Meat ( )
E. Garbage Disposal Fruit/vegetables ( )
Collection ( ) Mixed ( )
Burying ( )
Garbage cans ( ) B. Presence of Nutritional Disorder:
Burning ( ) 1. Goiter ( )
Open dumping ( ) Enlargement of the neck ( )
Others ___________________________ Hoarseness ( )
Dysphagia ( )
F. Food Storage 2. Anemia ( )
Covered ( ) Pallor ( )
Refrigerated ( ) Body weakness/ easy fatigability ( )
Uncovered ( ) 3. Vitamin A deficiency ( )
Night blindness ( )
“Pilak sa Mata” ( )
Others __________________________
VI. KNOWLEDGE, ATTITUDE, & PRACTICE Hepatitis ( )
A. Do you utilize the health center? Others ___________________________
Yes ( )
No ( ) F. Do you submit your children (0-12 months old) for immunization? ______________________________
Others __________________________
Name of Child DOB Immunization
B. Reason: BCG DPT OPV AM
Illness ( )
Family planning ( )
Dental ( )
Prenatal ( )
Postonatal ( )
Nutrition ( )

C. First person consulted in times of Illness:

MD ( )
Midwife ( )
“Hebularyo” ( )
G. Do you practice family planning?
Nurse ( )
Yes ( )
Hilot ( )
No ( )
BHW( )
Method ___________________________________________________________________________
Others ___________________________
If no, why? _________________________________________________________________________
D. Usual illness in the Family
H. Method of infant feeding
Breasdfeeding ( )
Mixed ( )
Bottle ( )

I. Subjects you want to learn in health education

Drug abuse ( )
Family planning ( )
What do you do for the condition? First aid measure ( )
Self-medication ( ) Nutrition ( )
Hospital ( ) Herbal plants ( )
Nursing ( ) Others _______________________________
Consultation ( )
Private clinics ( )
Others ___________________________

E. Other Diseases:
TB ( )
Skin Disease ( )
Leprosy ( )