TOTAL POPULATION

NUMBER OF HOUSEHOLDS

A. FAMILY MEMBERS AND CHARACTERISTICS

AGE
(0-2) 1 - 1 1 - 1
(3-7 ) 2 1 2
(8-12) 1 1 1
(13-17) 1
(18-35) 3 2 2 2 2 1
(36-55) 2 1
(56 ABOVE)
SEX
MALE 4 1 3 1 2 2
FEMALE 4 3 1 2 2 3

CIVIL STATUS
MARRIED 2 2 2
SINGLE 6 4 4 1 2 5
WIDOWED
SEPARATED
COMMON LAW
DIVORCED

EDUCATIONAL ATTAINMENT
Post Graduate
College Graduate 2 1
College Level 2
College Undergraduate 1 2
Highschool Graduate 1
Highschool Level 2
Highschool Undergraduate 2 2
Elementary Graduate
Elementary Level 1 1 1 1
Elementary Undergraduate 1
Preschool 1
Non Formal Education
not studying 1 1 1 1 1 2

OCCUPATION/EMPLOYMENT STATUS
PROFESSIONAL - - - - - -
SKILLED - - - - - -
NON-SKILLED - - - - - -
UNEMPLOYED 2 2 2 2 2 2
RETIRED - - - - - -
NONE 6 2 2 1 2 3

RELIGION
ROMAN CATHOLIC 8 4 1 5
MUSLIM
INC
BORN AGAIN 1
BAPTIST 3 2 4
JEHOVAH'S WITNESS

II. FAMILY HEALTH STATUS AND PRACTICES

A. Immunization and Nutritional Status
YELLOW CARD
Yes ALL
No
Severely
Wasted Wasted Normal Overweight Obese
Nutritional Status ALL NORMAL

B. Morbidity and Mortality

MORBIDITY:
ILLNESSES
HYPERTENSION - - - - - -
DIABETES - - - - - -
FEVER - - - - - -
COUGH AND COLDS - - - - - -
ASTHMA - - - - - -
VOMITING - - - - - -
HEADACHE - - - - - -
COMMUNICABLE - - - - - -
NON-COMMUNICABLE - - - - - -

CAUSES
LIFESTYLE - - - - - -
HEREDITARY - - - - - -
UNKNOWN - - - - - -

SEX
MALE - - - - - -
FEMALE - - - - - -
 AGE
(0-2) - - - - - -
(3-7 ) - - - - - -
(8-12) - - - - - -
(13-17) - - - - - -
(18-35) - - - - - -
(36-55) - - - - - -
(56 ABOVE) - - - - - -

WHO ATTENDED
HOSPITAL - - - - - -
RHU - - - - - -
DID NOT SEEK MEDICAL ATTENTION

MORTALITY:
DECEASED MEMBER OF FAMILY
YES - - - - - -
NONE - - - - - -

CAUSE OF DEATH
ILLNESSES
HEART ATTACK - - - - - -
TUBERCULOSIS - - - - - -
ACCIDENT - - - - - -
SUICIDE - - - - - -
OTHERS - - - - - -

AGE
(0-2) - - - - - -
(3-7 ) - - - - - -
(8-12) - - - - - -
(13-17) - - - - - -
(18-35) - - - - - -
(36-55) - - - - - -
(56 ABOVE) - - - - - -

SEX
MALE - - - - - -
FEMALE - - - - - -

WHO ATTENDED
HOSPITAL - - - - - -
RHU - - - - - -
DID NOT SEEK MEDICAL ATTENTION

C. Nutrition
1. BREASTFEEDING
YES ALL
NO

2. AGE OR MONTHS
0-6 MOS. - - 1 - - -
7-12 MOS. - - - - - -
13-24 MOS. 1 - - 1 - 1

3. REASONS FOR NOT BREASTFEEDING

NO BREASTMILK - - - - - -
SICK - - - - - -
GROWN CHILD - - - - - -
WORKING - - - - - -
PREGNANT - - - - - -
OTHERS - - - - - -

4. FOODS SUBSITUTE FOR BREASTFEEDING

AM/SEGGET - - - - - -
LUGAW 1 - - - - -
INNAPOY 1 - - 1 - 1
KAMOTE 1 - - 1 - 1
BANANA 1 - - 1 - 1
SQUASH 1 - - 1 - 1
EVAPORADA - - - - - -
INFANT FORMULA - - - - - -
WATER WITH SUGAR - - - - - -
MILK PRODUCTION - - - - - -
OTHERS MILK

D. Family Planning
AGE DURING PRIMIGRAVIDA
15 - 17 Y/O 1 1 1 1 1 1
18 - 35 Y/O - - - - - -
36 - 55 Y/O - - - - - -

NO. OF CHILDREN
1 - - - 1 - -
2 - 1 1 - 1 -
 3 - - - - - 1
4 1 - - - - -
5 - - - - - -
6 - - - - - -
7 - - - - - -
8 - - - - - -
9 - - - - -
10 - - - - - -

NO. OF PREGNANCIES
1 - - - 1 - -
2 - 1 1 - 1 -
3 - - - - - -
4 - - - - - 1
5 - - - - - -
6 1 - - - - -
7 - - - - - -
8 - - - - - -
9 - - - - - -
10 - - - - - -

NO. OF MISCARRIAGE
1 - - - - - 1
2 1 - - - - -
3 - - - - - -

CHILD BIRTH TYPES

NATURAL 4 2 2 1 2 3
ARTIFICIAL - - - - - -

FAMILY PLANNING METHODS

ABSTINENCE - - - - - -
PILLS - - - - - -
IUD - - - - - -
RHYTHM - - - - - -
CONDOM - - - - - -
LIGATION - - - - - -
VASECTOMY - - - - - -
INJECTION - - - - - -
WITHDRAWAL - - - - - -
OTHERS - - - - - -
NONE 1 1 1 1 1 1
 DOES RELIGION AFFECTS YOUR DECISION IN USING ANY FAMILY PLANNING METHODS?
YES
NO 1 1 1 1 1 1

E. BELIEFS AND PRACTICES

CHOICE OF FOOD FOR THE FAMILY - - - - - -
- - - - - -
PREGNANCY AND BIRTH - - - - - -
- - - - - -
CARE OF THE SICK - - - - - -
- - - - - -
CHILD FEEDING - - - - - -
- - - - - -
FOOD DISLIKES OF THE FAMILY - - - - - -
- - - - - -

F. ENVIRONMENTAL CONDITIONS
Type of Toilet
FLUSH TOILET - - - - - -
WATER SEALED 1 1 1 1 1 1
ANTIPOLO TYPE - - - - - -
OVERHANG - - - - - -
NONE

Type of Kitchen Sink

OPEN 1 1 1 1 1 1
BLIND

GARBAGE COLLECTION
OPEN RECEPTACLE 1 1 1 1 1
COVERED RECEPTACLE 1
NONE

WAYS OF DISPOSING
COMPOSTING 1 1 1 1 1 1
BURNING
BURYING
RIVERSIDE DUMPING
OPEN DUMPING
OTHERS

DOMESTIC ANIMALS AND LIVESTOCK

DOG 1
 NONE 1 1 1 1 1

LEFT A STRAY?
Yes
No 1 1 1 1 1 1

WATER SOURCES
NAWASA
WATER PUMP
DEEP WELL 1 1 1 1 1 1
SHALLOW DUG WELL
PROTECTED SPRING
UNPROTECTED SPRING

WATER CONTAINER
JUG 1 1 1 1 1 1
PITCHER
BOTTLE
CARAMBA
WATER DISPENSER
TUMBLER

WATER CONTAINER WITH COVER

YES 1 1 1 1 1 1
NO

DO YOU DRINK THE WATER DIRECTLY FROM THE WATER SOURCE?

YES 1 1 1 1 1 1
NO

WATER TREATMENT
CHLORINATE - - - - - -
BOILING - - - - - -
NONE - - - - - -

FOOD STORAGE
CABINET - - - - - -
COVERED PLATE 1 1 1 1 1 1
CHEST - - - - - -
REFRIGERATOR - - - - - -
HANGING BASKET - 1 1 1 - 1
CONTAINER
 III. SOCIO-ECONOMIC, POLITICAL AND CULTURAL FACTORS
Primary cost for living
OWNED TENANTED
FARMING 1
FISHING 1
LABORER
GOVERNMENT PRIVATE
EMPLOYEE
CARPENTER 4
VENDOR
BRGY. TANOD
OTHERS 1

MONTHLY FAMILY INCOME

below 5,000 1 1 1 1 1 1
5,001-10,000 - - - - - -
10,001-20,000 - - - - - -
20,001-30,000 - - - - - -
30,001 and above - - - - - -

Food Production Activities

A. GARDEN
Family Use For Selling
PIGGERY - - - - - -
POULTRY - - - - - -
FRUIT GARDEN - - - - - -
FRUIT TREES - - - - - -
FISHERY - - 1 - - -
NONE - - - - - -

Real Property
A. HOUSE OWNER
WIFE AND THE SPOUSE 1
SPOUSE'S RELATIVE 1 1 1 1 1
RENTED
TENANTED
COMMUNAL/GOVERNMENT PROPERTY
OTHERS

B. TYPE OF HOUSE CONSTRUCTION

LIGHT 1
MEDIUM
HEAVY 1 1 1 1 1
C. ADEQUACY OF LIVING SPACE
No. of Bedrooms
1 1 1 1 1 1
2
3 1
4
5
6

Utilities
A. PRESENCE OF ELECTRICITY
YES 1 1 1 1 1 1
NO

Appliances
RADIO 1 1 1
REFRIGERATOR 1
ELECTRIC FAN 1 1 1 1 1 1
GAS RANGE
TELEVISION 1 1 1 1 1
RICE COOKER
OTHERS
NONE

Decision Making
A. FAMILY EXPENSES 7
B. DAILY EXPENSES 7
C. EDUCATION 7
D. BARANGAY ACTIVITIES 7
E. OTHERS

Community Needs and Problems

lack of income lack of in lack of in lack of in lack of inco lack of in lack of in
financial problem financial financial financial financial pr financial financial
no work no work no work no work no work no work no work
Community Resources
A. RECOMMENDED MATERIALS
kayo(all), kawayan, barat
B. SUGGESTED BRGY. OFFICIALS
BRGY. CAPTAIN 1 1
BRGY. KAGAWAD - - - - - -
others - - - - - -
municipal mayor/governor/sanggunian 2 1 2 2 1 2

C. AFFILIATED ORGANIZATIONS
RIC 1 - - - - -
4 P'S 1 - - - - -
INDIGENT - - - - -
others (specify) 1 - - - - -
 TOTAL

4
5
1 4
1
2 14
3
31

1 14
2 17
31

6
3 25
31

3
2
3
2 3
2
4
-
1 5
1
1
-
- 7
31

- -
- -
- -
2 14
- -
1 17
31

3 21
-
-
1
9
-
31

ALL NORMAL

- -
- -
- -
- -
- -
- -
- -
- -
- -

- -
- -
- -

- -
- -
- -
- -
- -
- -
- -
- -
- -

- -
- -

- -
- -

- -
- -
- -
- -
- -

- -
- -
- -
- -
- -
- -
- -

- -
- -

- -
- -
 7
-

- 1
- -
- 3
4

- -
- -
- -
- -
- -
- -

- -
- 1
- 3
- 3
- 3
- 3
- -
- -
- -
- -

1 7
- -
- -

1 2
- 6
- 3
- 4
- -
- -
- -
- -
- -
- -
15

1 2
- 6
- -
- 4
- -
- 6
- -
- -
- -
- -
18

- 1
- 2
-
3

1 15
- -
15

- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
1 7
 -
1 7

- -
- -
- -
- -
- -
- -
- -
- -
- -
- -

- -
1 7
- -
- -

1 7
-

1 6
1
7

6
1 1
-
-
-
-
7

1
1 6
7

-
1 7

-
-
1 7
-
-
-

1 7
-
-
-
-
-

1 7
-

1 7
-

- -
- -
- -

- -
1 7
- -
- -
- 4
 1
1
-

-
4
-
-
1
TOTAL 7

1 TOTAL 7
- -
- -
- -
- -

- -
- -
- -
- -
- 1
- -

1
1 6
-
-
-
-
TOTAL 7

1 2
-
5
 TOTAL 7

1 6
-
1
-
-
-
TOTAL 7

1 7
-

1 4
1
6
-
5
-
-
-

BOTH PARENTS
BOTH PARENTS
BOTH PARENTS
BOTH PARENTS

lack of in lack of in lack of in lack of in lack of income

financial financial financial financial problem
no work no work no work no work no work

1 3
- -
- -
1 11
TOTAL 14

- 1
- 1
- -
- 1