QUESTIONNAIRE

Direction: Please answer the questions below by filling the blanks or putting a check (/) on the
space provided. Thank you.

Part I. Profile

A. Personal Data

Name (Optional): ___________________________

Age: ( ) less than 30 years old
( ) 30 – 39
( ) 40 – 49
( ) 50 – 59
( ) 60 y/o and above
Sex: ( ) Male ( ) Female
Civil Status: ( ) never married
( ) married
( ) uncoupled (separated/widowed)
( ) cohabiting
Educational Attainment:
( ) Elementary Undergraduate
( ) Elementary Graduate
( ) High School Undergraduate
( ) High School Graduate
( ) College Undergraduate
( ) College Graduate
( ) Post graduate studies
Type of Family:
( ) nuclear ( ) Extended
Number of children:
( ) none ()4–6
()1–3 ( ) 7 & above
B. Socio-Economic

Employment Status:
( ) Full-time employed
( ) Part-time employed
( ) Retired
( ) homemaker/houseband
( ) self-employed
( ) farmer
( ) fisherman
 ( ) vendor
( ) laborer
( ) driver
( ) businessman/businesswoman
( ) salesman/saleslady
( ) others, please specify _______________
Monthly Family Income:
( ) Below Php 999.00
( ) Php1,000.00 – 4,999.00
( ) Php5,000.00 – 9,999.00
( ) Php10,000.00 – 14.999.00
( ) Php 15,000.00 & Above
Type of Dwelling:
( ) made of light materials (wood, nipa, or bamboo)
( ) semi- concrete (concrete, wood/bamboo & nipa)
( ) permanent/concrete
Home ownership:
( ) owned
( ) rented
( ) rent free
( ) squatter area
( ) others, specify ______

Part II. Environmental Sanitation

Lighting:
( ) electricity ( ) Gas ( ) candle ( ) others, specify ____
Cooking Facility:
( ) electric stove ( ) gas stove ( ) firewood/charcoal ( ) others, specify _____
Food and water storage:
( ) refrigerated ( ) not refrigerated ( ) covered ( ) exposed
Source of Water:
( ) Commecial Faucet system (Pipe, NAWASA)
( ) Free Flow
( ) Water pump (Deep Well)
( ) Well
( ) Others, please specify ______
Garbage Disposal
( ) Decomposing ( ) Open Dumping
( ) Burning ( ) Garbage collection
( ) Land Filling ( ) waste segregation
Excreta Disposal
( ) Balot System
( ) pit latrines
( ) public toilet
( ) neighbor’s toilet
( ) pour-water toilet
( ) flush toilets
( ) Others, please specify ______

III. Family Health Practices

Do you cook foods for your everyday consumption:
( ) yes ( ) no

If no, where do you buy your food?

( ) food vendors
( ) talipapa
( ) carenderia
( ) fast food chains
( ) others, please specify _____
Hand washing before preparing food?
( ) yes ( ) no
Food that you usually eat?
( ) rice with vegetables
( ) rice with vegetables and fish
( ) rice with vegetables and meat
( ) rice with vegetables, fish and meat
( ) rice with food preservatives (toyo, salt, sugar, patis, bagoong)
( ) rice only
Main Meal Taken each day:
( ) once a day ( ) 3x a day
( ) 2x a day ( ) 3x a day or more
IV. Health Status
Are the children immunized? ( ) fully immunized ( ) partially immunized ( ) no
Pregnancy:
( ) 1st trimester
( ) 2nd trimester
( ) 3rd trimester
Prenatal: ( ) with prenatal Tetanus Toxoid: ( ) with TT
( ) without prenatal ( ) without TT
Common diseases/health problems in the family (Children):
( ) cough & colds ( ) fever
( ) rashes, skin problems ( ) eye & ear problems
( ) measles, mumps ( ) others, please specify ______
Common Diseases/health problems in the family (Adults):
( ) diabetes ( ) pneumonia
( ) hypertension ( ) asthma
( ) tuberculosis ( ) others, please specify _______
How do you manage/treat common diseases/health problems?
( ) use of herbal medicine
( ) consulting the faith healer (herbolario of the barangay)
( ) going to the botika sa barangay
( ) consulting healthcare providers in the rural health unit
( ) consulting a medical practitioner

- THANK YOU -
The Researcher