Professional Documents
Culture Documents
God – fearing
Governor Panotes Avenue, Nation – loving
Daet, Camarines Norte Law abiding
Earth caring
Tel. no. (054) 721-1281 local 102 Productive, and
Locally and Globally
Email: mabinicollege@hotmail.com competitive persons
1. IDENTIFICATION INFORMATION
Head of Family: ______________________
Address: _______________________________
Ethnicity: __________________________
2. HOUSING CONDITION
I. Type of House: Completed Partially Completed Independent
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Cooking Facility: Electric Stove Gas Stove Firewood/Charcoal
Others: ____________________
Others (specify):__________
a. Drinking Water
b. Household Use
Source: Hand Pump Tap/CNWD Deep Well
Others: ______________
Storage: Direct from faucet Covered Container
Uncovered Container
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IV. Domestic Animals
Kind Number Where Kept Sanitary Condition
3. FAMILY COMPOSITION
BIRTHDATE OCCUPATION
(Highest Attainment)
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11
12
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Owned: Yes No
Tricycle Bicycle Padyak Bus Taxi
Car PUV Jeepney Others:_________
Telephone
Internet
Television
Radio
Newspaper/Magazine
Cellphone
5. LANGUAGE KNOWN
Filipino Ilocano Bicol
English Bisaya Any Other:
_________________
6. A. NUTRITIONAL PATTERN
_____VEGETARIAN _____NON-VEGETARIAN
Staple Food: Rice Wheat Mixed
Vegetables: Grown Purchased Quantity used per day: ___gm/kg
Milk: Quantity used per day: ___ liters
Non-vegetarian dish: Specify: __________ How often: ___________
Obese
Overweight
Normal
Wasted
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Severely wasted
- When was the last time you visited the doctor/health center for a routine check-up?
Within the last 12 months Within the last 2 years
Between 2-5 years Over 5 years ago
I have never had a routine check-up/visit
-
- Are you able to visit a doctor/health care worker when needed?
Always Sometimes Seldom Never
- Which of the following have stopped you from getting the health care you need? (Check all that
apply)
Too expensive
Lack of transportation
Health worker is not attending
Others, please specify: ________________________________
Yes l NO
- Select any of the following preventive procedures you have had in the last year.
Vaccination, please specify ___________________________
BP Check-up Prostate screen
Cholesterol screen Dental cleaning
Blood Sugar check Mammogram
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ECG Colon/Rectal Examination
Vision screening Pap smear
Hearing screening Others, please specify _________________
DATE GIVEN
If NO, why have you not used a contraceptive or birth spacing method?
___________________________________________________________________________
_____________________________________________________________________
9. HEALTH
a. Where do you go if you or any of your family member is sick? ___________________
b. Who do you consult when you or any of your family member is sick? _____________
c. When was the last time you or any of your family member had consultation/visit to the
doctor? ___ __ For what reason: _______________________________
d. When was the last time you or any of your family member visit a dentist? ________________
e. Is there any medication that is currently being taken by you or any of your family member?
If YES, please name them: ________________________________________________
f. Is any member of the family currently with sickness or condition? ___ YES ____ NO
What is the sickness/medical condition? ___________________________________________
h. Is their death in the family for the past year? ___ YES ____ NO
If YES, for what reason? _________________________________________________________
i. Have you attended any health-related meetings or seminar? ___ YES ____ NO
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If YES, what is the topic? __________________________________________________________
If NO, what is the reason why you don’t attend a health-related seminar, meetings, and the like?
_____________________________
j. Which of the following do you think are the FIVE most important factor a healthy community?
Please check 5 only.
_____ Child care
_____ Prenatal/Postnatal care
_____ Low death rate
_____ Low illness rate
_____ Healthy behavior and lifestyle
_____ Healthy food sources
_____ Clean and safe environment
_____ low level of child abuse
_____ Emergency and disaster preparedness
Others, please specify:
___________________________________________________________