PRENATAL NUTRITION AND IMMUNIZATION

Demographics OB History
Name:____________________________ Gravida: _________
Age:___ Term:
Civil Status:_____ Para: _________
Weight (kg/lbs):___________ Living: _________
Pre-pregnancy weight (kg/lbs):_________ Abortion: _________
Date of Last Menstrual Period (MM/DD/YYYY): (__/__/____) Multiple Pregnancy: _________
Estimated date of delivery (MM/DD/YYYY): (__/__/____) Stillbirth: _________

Number of Tetanus Toxoid shots received: _____________________

Schedule (On Schedule/Behind Schedule; Refer to the table below): __________

Tetanus Toxoid Immunization Schedule Reference

TT1
Immediate

TT2
At least 1 month after TT1

TT3
At least 6 months after TT2

TT4
At leat 1 year after TT3

TT5
At least 1 month after TT4
 1. Do you take food supplements?
❏ Yes
❏ No

2. If yes, what food supplements do you take? [can mark multiple items]
❏ Multivitamins [e.g. Centrum, Enervon, Amway, etc]
❏ Ferrous sulfate
❏ Folate
❏ Ascorbic acid only
❏ Vitamin A
❏ Others [please specify]: __________

CHILDHOOD IMMUNIZATION

Name of Family: ___________________ Name of Student: ________________________

Name Age Vaccines

0 – 7 years old >7 years old
Pentavalent OPV/IP Hepatiti PC Teanus
BCG MMR Varicella Influenza HPV Tetanus - Diphteria
V sB V toxoid

Status: C – complete, N – non immunized, O – ongoing and S – stopped;

 FAMILY PLANNING

Name of the Household Head: ______________________ Total No. of couple in the family: ______

COUPLE NO. ____

Name of Wife: ________________________________ Age: _____ Classification: Reproductive Age ( ) Menopausal ( )
Name of Husband: _____________________________ Age: _____
No. of Children: ________

Does the couple use any Family Planning Method? Yes No

If YES,
Family Planning Method currently being used: ________________
Start of Use: ___________________
Duration of Use: _____________________
Remarks/comments: __________________________________

Any plans to shift to other method/s? ________________

Reason/s for probable plans of shifting (please specify):____________________________________

If NO,
Reasons of never using any method:
 Fear of side effects  Lack of information  Financial constraints  Problem of availability
 Others (please specify) : ______________________________________________________

Family Planning Methods

1. Combine Oral Contraceptives 8. Copper Intrauterine Device 15. Calendar based method: 21. Bilateral Tubal Ligation
2. Combined Injectable Contraceptives 9. Intrauterine System Standard Days 22. No scalpel vasectomy
3. Transdermal Patch 10. Male condoms 16. Two Day Method 23. Withdrawal
4. Vaginal Ring 11. Female condoms 17. Billings Ovulation Method 24. Abstinence
5. Progestin-only pills 12. Diaphragm 18. Basal Body Temperature Methods
6. Progestin – only Injectables 13. Cervical cap 19. Symtothermal Method
7. Subdermal implants 14. Spermicide 20. Lactational Amenorrhea Method
(For Contraceptive Use: Non-married Individual)
Name: ______________________________________________________
Age: ________

Are you using any Contraceptive Method? Yes No

If YES,
Contraceptive Method being used: ___________________________
Start of Use: ______________
Duration of Use: ______________
Remarks/comments: ________________________________

ENVIRONMENTAL INDICES

Access to Basic Safe Water Supply and Use of Safety Managed Drinking-Water Services

Family/Household: ____________________________
Put a Check ( ) mark on all possible choices that applies to your family/household. You are allowed to select multiple choices:

1. Our household gets our source of water from the following:

⃝ Rain, River, Streams, Ponds, Lake, Springs
⃝ Communal Faucet, stand post
⃝ Water works, Individual house connection, family owned pumps
⃝ Open dug well, Deep well
⃝ Others specify: _________________
2. Please check the appropriate box for the use of the above-mentioned answers

Faucet, stand post

family owned Individual house

Streams, Ponds,

Open dug well,

______________Others specify:
connection, Water works,
Lake, Springs Rain, River,

Deep well
Communal
Check to the corresponding
water source for each
household chore

Taking a Bath
Washing Clothes
Cleaning the House
Others specify: _________

3. Our household uses the following sources for drinking

⃝ Water-refilling Stations / Commercialized bottled water
⃝ Tap Water (Specify source: _____________________)
⃝ Rain Water
⃝ Others specify: ________________

Specify your source of water used for cooking: _______________________

For drinking water sources not from water refilling stations / commercialized bottled water please answer number 4

4. We prepare the above-mentioned water source through:

⃝ Boiling
⃝ Filtration
⃝ Chlorination
⃝ Others specify: _______________________

Remarks (use of prepared water): ___________________________________

 Food Safety and Sanitation

Does the household prepare their own food? (Select only one from the selection.)
 Yes
 No, ready-to-eat food bought from outside is mostly consumed
 Both, the household buys and cooks their own food

If no, answer only questions A1 and A2; B3 and B4; C1, C4, and C5; lastly, D1, D2, D3, D4.
If yes or both, answer all the questions below

A. Handwashing and Hygiene Practices

1. Handwashing before food handling (Select only one from the selection.)
 With water
 With soap and water
 Not done

2. When to wash hands (Select all that applies.)

 After using the toilet
 After handling pets/animals
 After coughing/sneezing
 After touching bare body part
 After handling raw meat/food
 After handling waste
 Not done

3. Does any individual handle food when sick?

 Yes
 No
B. Food Sanitation
1. Washing of fruits and vegetables
 Yes
 No

1.1 If yes, how many times does the handler wash rice, fruits, vegetables, and meat before cooking? (Check the frequency of washing rice, fruits, vegetables and meat/poultry.)

Frequency Rice Fruits Vegetables Meat/poultry

Does not wash
Once
Twice
More than twice

2. Source of water for washing of food (Select all that applies.)

 Tap water
 Mineral Water
 Rainwater
 Others: ______________

3. Utilization of serving spoon/utensils (Select only one from the selection.)

 Yes
 No, we use our own utensils
 No, we use our bare hands
 Others: _________________

4. Washing of utensils (Select only one from the selection.)

 With soap and water
 With water only
 Not practiced
 Others: _________________

C. Storage/Preservation
1. Storage of utensils (Select only one from the selection.)
 Covered container or cabinet
 Left to open in drainer
 Others: _________________
2. Storage of fruits and vegetables (Select only one from the selection.)
 Refrigerator
 Room temperature

3. Usual hours before the cooked food consumed (Select only one from the selection.)
 Within 4 hrs after it was cooked
 4-8 hrs after it was cooked
 Within 24 hrs after it was cooked
 After 24 hrs after it was cooked

4. Storage of leftover food (Select all that applies.)

 Covered container
 Use of plastic wrap/plates
 Refrigerator
 Placed in table with plastic food cover
 Do not cover leftover food

.5. Preparation of leftover food before eating (Select only one from the selection.)
 Reheated
 Eating without reheating

D. Kitchen Sanitation
1. Cleaning of kitchen environment (Select only one from the selection.)
 With detergent/antibacterial solution
 With water only
 None

2. Frequency of cleaning the kitchen and dining area (Select only one from the selection.)
 Every after use
 Hours after use
 A day after use
 Does not clean the kitchen and dining area

3. Kitchen has: (Select all that applies.)

o Insects/pests:
 Cockroaches
 Flies
  Mice
 others (specify): __________

4. Storage of chemicals (Select only one from the selection.)

 Stored in another storage apart from the food storage, with labels
 Stored in another storage apart from the food storage, without labels
 Stored near or within the food storage
 Others: ____________

SOLID WASTE MANAGEMENT

Instruction: Mark with a check (✓) the following square brackets corresponding your answers.

A.) Have you ever heard of proper solid waste disposal?

[ ] Yes
A.1.) If yes, on what way/platform?
[ ] Radio
[ ] Television
[ ] Through Internet/Social media
[ ] In School
[ ] On Posters
[ ] From a Friend
[ ] Through Barangay Educational Activities
[ ] Others:___________________
[ ] No

B.) Where do you put your garbage/s?

[ ] Carton
[ ] Sack
[ ] Trash can
[ ] Others:__________________________________

C.) Do you segregate?

[ ] Yes
[ ] No
D.) What do you do with your biodegradable waste? (Check all that apply)
[ ] Dispose to MRF
[ ] Collected by garbage truck
[ ] Composting
[ ] Burning
[ ] Open dumping
[ ] Others: ___________________________

E. What do you do with your non-biodegradable waste? (Check all that apply)
[ ] Recycling
[ ] Dispose to MRF
[ ] Collected by Garbage Truck
[ ] Burning
[ ] Open dumping
[ ] Others: ____________________________

TOILET FACILITIES

Check one box per number.

1. Do you have access to toilet facility?
 Yes
 No
If no proceed to #8
2. What is the type of toilet used?
 Water sealed bowl with floor covering the pit connected to a septic tank
 Open pit latrine with wood covering when not in used
 Others: ______________
3. How many families use the toilet?
 1 family
 2 families
 More than 2 families
4. Where is the toilet located?
 Inside the house
 Outside the house
5. What is the source of water supply in the toilet?
 Installed faucet with water from community water system
 Stored water from rain, water well and any other outside water source (ex. river, lake)
 Others: ___________________
6. What do you use in cleaning the toilet?
(Note: check all the materials applicable)
 Soap
 Bleach
 Water
 Others: ______________
7. How many times do you clean the toilet?
 Daily
 Weekly
 Monthly
 Others: ___________________
8. If no access to toilet, where do you relieve yourselves?
 Outside the house in an open area
 Potty (arinola)
o How many members have no access to toilet? ____
9. If potty, where do you dispose the waste?
□ Open pit
□ Open area
□ Body of water (river, lake, sea, etc.)
10. If diaper is used, how is it disposed?
□ If yes, what type of diaper?
o Disposable? _____
o Cloth? _____
□ If disposable, where do you dispose the diaper?
o Open sewage canal? ____
o Open area? ____
o Garbage container? ____
□ If cloth, where do you dispose the excrement?
o Toilet? _____
o Open sewage canal? _____
o Open area? ____
 SEWAGE COLLECTION AND DISPOSAL

1. Where does the wastewater from your toilets go? (check all that apply)
(_) Private closed septic tank
(_) Open Drainage to nearby bodies of water
(_) Other arrangements, please indicate: ________

2. If the household has a closed septic tank, how often do you need to have it pumped out? (check one only)
(_) Every 3 years
(_) Last 3 – 5 years
(_) Last 6 – 10 years
(_) More than 10 years
(_) Do not know/ not sure

3. What wastewater disposal system for kitchens/showers does your household currently use? (check all that apply)
(_) Drainage canals
(_) Roadside
(_) Open drainage to nearby bodies of water
(_) Catch Basin
(_) Bato System/Bored Hole
(_) Simple DIY tubig pangsala
(_) If others, please indicate: ____________________

4. Where does your household obtain drinking water?

(_) City Waterworks
(_) Deepwell or pump
(_) Mineral water purchased
(_) Springwater

5. Location of sewage disposal system in relation to a source of water supply:

(_) Less than 25 m
(_) At least 25 m

6. Are there any problems in the drainage of water like clogging?

(_) Yes
(_) Sometimes
(_) No
(_) If other problems/defects, please indicate: ___________
 PETS & LIVESTOCK/ PESTS & VERMIN CONTROL

FAMILY/HOUSEHOLD: _______________________
ADDRESS: ________________________________
RESIDENTIAL AREA: [ ] URBAN
[ ] RURAL

A. PETS
1.) DO YOU HAVE PETS IN YOUR HOUSEHOLD?
[ ] YES
[ ] NO (go to Section B)

2.) ANSWER THE FOLLOWING QUESTIONS BELOW:

A. Indicate what kind of pet and how many. (Example: cat-2, dog-1 )

B. Is/Are the pet/s sheltered?

[ ] YES [ ] NO

If YES, what pet/s is/are sheltered?

_____________________
How are they sheltered?
[ ] leashed
[ ] caged
[ ] inside house
[ ] others, specify: ________

C. Do you clean/bathe your pet/s?

[ ] YES [ ] NO

IF YES, how often is bathing done to your pet/s?

[ ] daily
[ ] weekly
[ ] monthly
[ ] others, specify: __________
D. Is/Are your pet/s immunized?
[ ] YES [ ] NO

If YES, what pet/s is/are immunized and what immunization was given?

E. Have you dewormed your pet/s?

[ ] YES [ ] NO

If YES, what pet/s? ______________

F. How are excreta of your pet/s disposed?

(Check all that apply, and indicate how often it is done.)

FREQUENCY
METHOD
(sometimes, often, always)

[ ] Left on the ground

[ ] Buried in ground

[ ] Covered with sand/soil

[ ] Used as fertilizer

[ ] Others, please specify:

B. LIVESTOCK
1.) DO YOU HAVE LIVESTOCKS IN YOUR HOUSEHOLD?
[ ] YES
[ ] NO (go to Section C)

2.) ANSWER THE FOLLOWING QUESTIONS BELOW

A. Indicate what kind of livestock animal/s and how many. (Example: cow-1, chicken-2 )

B. Is/Are the livestock animal/s sheltered?

[ ] YES [ ] NO

If YES, what livestock animal/s is/are sheltered?

_____________________
How are they sheltered?
[ ] caged
[ ] inside house
[ ] others, specify: ________

C. Do you clean/bathe your livestock animal/s?

[ ] YES [ ] NO

If YES, how often is bathing done to your livestock animal/s?

[ ] never
[ ] daily
[ ] weekly
[ ] monthly
[ ] others, specify: __________
 D. How are excreta of your livestock animal/s disposed?
(Check all that apply, and indicate how often it is done.)

FREQUENCY
METHOD
(sometimes, often, always)

[ ] Left on the ground

[ ] Buried in ground

[ ] Covered with sand/soil

[ ] Used as fertilizer

[ ] Others, please specify:

C. PEST & VERMIN CONTROL

1.) What specific pest/s have you seen in your household? (Check all that apply and indicate the frequency of their sightings.)

FREQUENCY
PESTS
(sometimes, often, always)

[ ] Rats

[ ] Cockroaches

[ ] Flies

[ ] Dog fleas

[ ] Mosquitoes

[ ] Termites

[ ] Others:
2.) Have you done any control measure to eliminate the pest/s?
[ ] YES
[ ] NO

If YES, answer the questions below.

a) What specific control measure/s is/are done? (Check all that apply and indicate how often they are done.)

FREQUENCY
CONTROL MEASURES
(sometimes, often, always)

[ ] Rat poison

[ ] Fly paper

[ ] Moth ball

[ ] Pesticides

[ ] Anti-flea shampoo

[ ] Flea spray

[ ] Others:

b) If spraying repellants and pesticides in your household, are there people in the vicinity?
[ ] YES [ ] NO

3.) Is fogging done in your community?

[ ] YES [ ] NO

If YES, are there people in the vicinity when fogging is done?

[ ] YES [ ] NO

4.) Do you dispose your cans/bottles of insect spray used control measure products?
 [ ] YES [ ] NO

If YES, how are they disposed? (Check all that apply and indicate how often it is done.)

FREQUENCY
METHOD
(sometimes, often, always)

[ ] Thrown with garbage/ practices proper disposal

[ ] Buried in ground

[ ] Burned

[ ] Others: