MSU-College of Medicine Student’s Name: _______________________

Batch 2023 Family’s Name: _______________________

DEMOGRAPHICS AND SOCIAL INDEX HISTORY

Family Size: Type of Family:

Residence: □ Nuclear □ Blended
□ Extended □ Others:

Name Role in the Family1 Sex Age Birth date Birth Registry Status2 Civil Status3
(M/F) (mm/dd/yy) (Y/N)

1-family head, husband, wife, son, daughter,uncle,aunt 2-Birth is registered at the civil registry
*if others please specify 3-(S) Single, (M) Married, (D) Divorced, (S) Separated, (W) Widowed

Membership to Government Programs

PhilHealth
Members Status1

4Ps Members

1 – Active, Inactive
 ECONOMIC STATUS

Type of Type of Total Monthly

Name Age Occupation Employment1 Other Sources4
Business2 Employment3 income
1.
2.
3.
4.
5.
6.
7.
8.
1- Place G(Government), P(Private), S(Self-Employed), N(None)
2- IF Self-employed only, please indicate type of business (ex. Sari-sari store, eatery, online seller, farm, etc.)
3- Place R(Regular), C(Casual), PB(Project-based), JO(Job Order), N(None)
4- Place Pn(Pensions), GA(Government Assistance), AR(Assistance of Relatives) or N(None)

For Working Members:

Monthly Budget Allocation

Utilities Miscellaneous
Food Health/Medical Care Education Savings
Water Electrictiy Rent Transportation Vices Internet Loans1

1- IF APPLICABLE, please specify until what month and year

SOCIAL INDICES

EDUCATION

Educational Attainmentb School Attendanceb

Rolea Name Age Highest Profession Able to Grade Level Grade Level
educational write and attended currently enrolled
attainment read (AY: 2019- (AY: 2020-2021)
(Y/N) 2020)

a
Role: indicate (mother, father, 1st child, 2nd child, 3rd child, etc); others: specify
b
Educational Attainment & school attendace: indicate (NFS= no formal schooling; G1-G12 = Grade 1-12; EG= elementary graduate; JG=Junior High Graduate; SG=Senior High
Graduate; C1- C5 = 1st -5th year college; CG=College Graduate; ML= masteral level, MG= masteral graduate, PhD= doctorate level,)

TRANSPORTATION AND COMMUNICATION

PUBLIC PRIVATE

__Jeepney __Tricycle __Motorcycle __Pedicab Others: __Bicycle __Motorcycle __Automobile Others: _______
___________
Most commonly used mode of transportation: ___ Public ___ Private

If public/private, how do you often use this? ___ Seldom ___ Somtimes ___ Frequently ___ Always

Means of Communication

__Telephone __Cellphone __ Internet Others:

____________

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

I. Nature of the House

A. What type of house does the family have?
[ ] Single-House [ ] Duplex
[ ] Multi-Unit Residential [ ] Others:                  

B. What is the house made up of?

[ ] Wood [ ] Cement
[ ] Mixed [ ] Others:                      

C. Is there a need for repair?

[ ] Needs no repair
[ ] Needs minor repair (leaky roof, leaky faucets, worn out floor)
[ ] Needs major repair (e.g. roof and/or wall replacement, foundation problems)

D. How many floors does the house have?                 

II. Property Ownership

A. What is the state of ownership of the house?
[ ] Owned
[ ] Not Owned
[ ] Renting
If renting, monthly rental:                        
[ ] Free (Allowed to stay in the house)

B. What is the state of ownership of the lot?

[ ] Owned
[ ] Not Owned
[ ] Renting
If renting, monthly rental:                        
[ ] Free (Allowed to occupy the area)

III. House Features

A. Security
i. How many doors does the house have?                  

B. Ventilation
 i. How many windows does the house have?   __
ii. What is the average size* of the windows in the house?
[ ] small
[ ] medium
[ ] large
C. Bedroom
i. How many bedrooms does the house have?              
ii. How many persons sleep in every bedroom?               
iii. What do you usually use for sleeping?
[ ] Bed
[ ] Floor (Banig)
[ ] Hammock (Duyan)
[ ] Others:                
D. Toilet Facility
i. Does the house have toilet facility?
[ ] present
If present, location:
[ ] inside the house [ ] Outside house [ ] Others               
[ ] Absent

IV. Resources
A. Do you have electricity?
[ ] Present
If present, where do you get your electricity?                                   
[ ] Absent

B. What is your source of lighting?

[ ] Electricity [ ] None
[ ] Kerosene [ ] Others:                             

C. What do you use as fuel for cooking?

[ ] Electricity [ ] Wood
[ ] Kerosene [ ] Others:                           
[ ] LPG
[ ] Charcoal

D. What is your water source for the following:

i. Laundry/Bathing
[ ] Barangay/City Water District
 [ ] owned
[ ] shared
[ ] communal
[ ] Deep Well
[ ] owned
[ ] shared
[ ] communal
[ ] Spring
[ ] Others:                              
ii. Cooking
[ ] Barangay/City Water District
[ ] Deep Well
[ ] Spring
[ ] Others:                             
iii. Drinking
[ ] Barangay/City Water District
[ ] Deep Well
[ ] Spring
[ ] Others:                           

SOCIAL AND POLITICAL CHARACTERISTICS

A. Leadership Structure
1. Who is the head of the family?
❏ Mother
❏ Father
❏ Eldest sibling
❏ Grandfather
❏ Grandmother

2. Who manages the money and resources and decides for the family?
❏ Father has more authority.
❏ Mother has more authority.
❏ Both father and mother have authority.
❏ None of the above.

3. What is the political set-up in the family?

❏ There are few or no rules set in the family.
❏ There are strict rules set in the family.

4. What is the type of discipline that is practiced by the head of the family?
❏ With corporal punishment (spanking, slapping, pinching, pulling, twisting, or hitting with an object)
❏ Without corporal punishment

B. What are the social/political organization/s the family member/s is/are part of? List below the name and organization and position of each family member. Skip if this does not apply.
Family member:___________________ Organization and Position:______________________
Family member:___________________ Organization and Position:______________________
Family member:___________________ Organization and Position:______________________
Family member:___________________ Organization and Position:______________________
Family member:___________________ Organization and Position:______________________

C. Are there registered voter/s in the family?

❏ Yes
❏ No
If yes, how many are registered voter/s? __
If yes, list down the names of the registered voter/s.
Names of voter:_______________________________
Names of voter:_______________________________
Names of voter:_______________________________
Names of voter:_______________________________
Names of voter:_______________________________

D. Recreation and Vices

1. What are the recreational activities does the family do? Tick what applies.
❏ Watching television together
❏ Family day/going outside together
❏ Playing sports
❏ Karaoke
❏ Cooking together
❏ Others: _____________

2. Are there any smoker/s in the family?

❏ Yes
❏ No
If yes, how many are smoker/s in family? ___
If yes, for each family member in every row, state the number of packs of cigarettes per day consumed and the years of smoking.
Packs of cigarettes per day consumed Years of smoking

3. Are there any drinker/s of alcoholic beverages in the family?

❏ Yes
❏ No
If yes, how many are alcohol drinker/s in family? ___
If yes, what are the types of alcoholic beverages consumed by family member/s? Tick what applies.
❏ Beer
❏ Wine
❏ Gin
❏ Rum
If yes, for each family member in every row, state how often do the family member/s drink alcohol. Refer to the legend on right side.
 Frequency *

*Frequency: Always/ Sometimes/ Often

4. Are there any gambler/s in the family?

❏ Yes
❏ No
If yes, how many are gambler/s in family? ___
If yes, what are the types of gambling in which family member/s is/are engaged to?
(Tick what applies):
❏ Tong-its/Card game
❏ Mahjong
❏ Swertres
❏ Sabong
❏ Bingo
❏ Poker
❏ Others: ________
If yes, for each family member in every row, state how often do the family member/s gamble? Refer to the legend on right side.
Frequency *

*Frequency: Always/ Sometimes/ Often

5. Are there any illicit drug user/s in the family?

❏ Yes
❏ No
If yes, how many are illicit drug user/s in family? ___
If yes, what are the types of illicit drug in which family member/s is/are taking? Tick what applies.
❏ Shabu
 ❏ Marijuana
❏ Cocaine
❏ Others: _______

CULTURAL CHARACTERISTICS

A. CULTURAL CHARACTERISTICS
Religion: ______________ Ethnicity: _______________
Dialect: □ Cebuano □ English □ Tagalog □ Maranao □ Others, specify: _____________

B. CULTURAL BELIEFS RELATED TO HEALTH

B.1 What are your cultural beliefs on the causes of disease/disorder?
□ Buyag □ Sumpa □ Karma (Gaba) □ Barang/Gidaot
□ Supernatural Creatures: (wakwak, engkanto, balbal, etc.)
□ Others, specify: ____________________________
B.2 How do you treat and manage diseases?
□ Yamyam □ Habak/Anting-anting □ Hilot □ Lana/Oil/Liniments
□ Albularyo □ Tandok □ Tuob
□ Animal potions (snake, lizard, other animal parts)
□ Herbal decoctions (tawa-tawa, lagundi, sambong, etc.)
□ Others, specify: ____________________________

PUBLIC ASSISTANCE AVAILED BY FAMILY MEMBERS

Members How often is it used Not a member

a. PhilHealth ___________ □ always □ sometimes □ never □
___________ □ always □ sometimes □ never □
b. 4P’s ___________ □ always □ sometimes □ never □
___________ □ always □ sometimes □ never □

c. SSS ___________ □ always □ sometimes □ never □

___________ □ always □ sometimes □ never □
d. GSIS ___________ □ always □ sometimes □ never □
___________ □ always □ sometimes □ never □

e. Others, please identify ___________ □ always □ sometimes □ never

___________ □ always □ sometimes □ never

Who do you approach for assistance when encountering problems (legal, medical)?
Check all that apply.

❏ Mayor
❏ Vice Mayor
❏ Councilors
❏ Barangay Captain
❏ Barangay Officials
❏ SK Chairman
❏ Kagawad
❏ Purok President
❏ Neighbor
❏ Resident doctor
❏ Nursing aid
❏ Public Attorney’s Office
❏ Non-governmental Organization (Red Cross)

Are you aware of the available assistance offered by the DSWD? If yes, check all that
apply.
❏ Transportation Assistance
❏ Burial Assistance
❏ Educational Assistance
❏ Food Assistance
❏ Calamity Assistance