Age: Sex. S800 ad Tf nat the Heed of the Farmily) |, Family Data 7 o ead of the ary: we B. Name of Spouse: by aetewegs C Address: Brgy’ ma ral No: 0745 [lt G49 D. Educational Attainment i, Husband: e ii, Wife: ve E Length of Residency: \ F.Ethnic Origin: Alan G Family: lear ( Extended () H Religion: No. of Children: a Merten o We Homer ett Sex Status Education Ml, Socio Economic Data ‘A Source of Income ‘Occupation: Palvoy Farming Husband: Wile: jon Employed () Unemployed () ‘Self-employed (+ ‘Monthly Income i Bolow P 2,000 () 2,000-5,000() spiehoor 8.0000) more than P8,000(y— Family Expenditures “ ‘Scanned with CamScannerConcrete (~ Wood () ‘Scanned with CamScannerPublic hospital (— 8. Indigenous health workers Trained “hilot * () BHW (}— | “Herbularyo" (6) — | C. Sources of health funds: | Government \)—— NGOs/POs () | Nutrition A Food preference Fish (4 Fruits/ vegetables (¢— Meat (¥— B. Common Rice and egg (— Rice and noodles ()— ‘Scanned with CamScanner. Usual ness in the family: AYy ie What do you do for this condition? ‘Self- medication (:) Consultation (4“Hospital () Private clinics () Nursing () Others: E Others diseases 7B () Leprosy () ‘Skin disease () Hopems {) Others allergies F Do you submit your children (0-12 months) for immunization? Ms (Name of Child Birthday Immunization BCG DPI OPV AM = 6.00 you practice family planning? Yes K-No () Method: Ino, why? ‘Scanned with CamScanner‘CORMLINITY HALT ASBEREMENT FOIA cretomt_ {Nl Yui (usren ow Fang Teer Pa ‘A tad ofthe tty: _—_ be 1. Mare oF Spe GC ctroan: 20, ra 1B. Revestonal Aloe Chambon eee yine 1 Wee | Legh ot Rasen Fiiecrone ©. Vary Niele VPEvionded tp H. Rigi Ut Socio Economic Data A, Souarca of income Occupation Feit Hea —— TO, a Wit: Employed ()— Unonnioyed Ty ‘Monty: neorne Bolaw P 2.000 () 5.001 -P8,000/) 8 Fam Exoencsturos a 2.000-P 5,000 () ‘more than F 8,000 af 1. Food Bolow P50) P50-75/) More than 70 2 Choihing numberof tinos oF buying ‘Once a yor) Thrice a year i 3. Houting Wator ¢): Aivctioty iy Cad 0 a te tity Sheet 9 Twive () ‘Scanned with CamScannerentiation: Poort) Ching Adaquiate ¢4° Surroundings Clean (7 8 “Artesian well (J NAWASA (¥” c Retiigerated Uncovered () Containers used Fate Gy loys) Bolles) Others: D. Tolet Facies ‘Sanitary, Faush § Others: ‘Shared (} Unsanitary: “Balorsystom () Otrors E Garbane Disposal Gotlection (-~ oars cane) hare F Pood Storsoe Refrigerated ( Wood) Mah stiee() Good Lf {Inadequate () Dirty () Deep weil () Others Covered () Pitprtyy () ‘Owned () ‘Buming () ‘Open dumping ( ) Uncovered () ‘Scanned with CamScannerHorta) = Barangay hasty enen () Morhot () Private sinc () | Private hagpkat() 8 axgamnus nee mtd nina at" BROW Uniraineed 00") rerbuneryo" (BP ©. Soames of heath it Privates’S werner one E Mtrtion A. Eosstiuete san (4 abe Moat’) Mivod 4 8 cocinon 2 Sanna Fox end oochts 7 Rive arid noodtng Others: C. Presence of Nutritional i 1 Goll Exiangnmart ofthe o0ck () Dyaphoaia (9 ‘Moarsoness () ‘Others 2. Aner Palo at me Easy fatigabiaty () 3. Vitam A doficieney seein “Pitok sa mata” () 4. Otter \owledge, Attitude and Practice 4 Bo you uliew the hotth Hoo, why? —S.foason Sheet — Mor: Yosi¢) No) Scanned with CamScanner© Umea! was 0 tamey What do you do far sr comcttion? ‘Se® mectcation ()/Consatati (Hossa YF Priite cinvcs {) Nursing {) Others E Cates domamee TBI) Leprosy () Sun cisease () Hepatiee() Ones F Do\pou seit your chaeron (0:12 mst) fac immenieation? Plame of Chet Bartha imemancration ace oer ‘OPv.AN © Do you practice famity planning? Yes () No‘ Method it, why? M4 Motncd of infant teaaing Ecvast () otto (3 ‘Mixed () 4 Subjects you want to fear in health education: Drug abuse () ‘Nutrition ¢) Famity planning ()_- Herbal plants () First art moasure (f Others tntorvinwedt by: MOAN Seti Date: Mpls TS ap Tie Re ‘Scanned with CamScanner‘Scanned with CamScanner‘Scanned with CamScanner‘Scanned with CamScanner‘Scanned with CamScannerH, Religion: I. No, of Children: J. Members of the Household: Wi. Socio Economic Data A, Soe of ncomefo pee ‘Occupation: Husband: 5 “eli 0 ‘Self-employed a ly Below P 2,000 () 2,000 - P 5,000 () 5,001 - P-8,000() more than P 8,000 B. Family Expenditures 1. Food: Below P50 () P 50-75() More than P70 ()-—~ 2, Clothing number of times of buying Once a year () ‘Thrice @ year() Scanned with CamScannerPoor (). eeree om ‘Surroundir can Dirty () 2 B. Source of Water Supply. _ ‘Artesian well (, (NAWASA. a c ‘Storane of Donking Water Refrigerated Covered () pore) Oo Containers used: Plastic ()-€lay jars () Bottles () Others: D. Toilet Facilities Sanitary: Flush Pit privy () Others Owned () ‘Shared () Unsanitary: “Ballot” system () Others — Sathane Disppset” Collection ‘Buming () ig Burying () Open dumpi Garbage cans () Others ere Uncovered () ‘Scanned with CamScanner2 induanous hea wots Trained *hilot” () BHW Cee “Herbularyo” Untrained “hitot” ( ) c health funds: Govemment () Private NGOs/POs () Others: E. Nutrition _. A Food preference Fish () Fruits/ vegetables () Meat () Micke B, Common Rice and egg Rice and sardines () Rice and noodles () Others: . Presence of Nutritional Disorder. 1, Goiter Enlargement of the neck () Dysphagia () Hoarseness () Others: 2. Anemia Pallor () Easy fatigabilty () Body weakness () 3. Vitamin A deficiency Night blindness () “Pilak sa mata” () BATE np ears 4. Others: Scanned with CamScanner0 “Herbularyo" ( ) Others D. Usual illness in the family er TA SToN What do you do for this condition? Pe oe yom () Consultation (¥-Fospital () Privat cnies () Nursing ( ) Others: E. Others diseases 7B() Leprosy () ‘Skin disease () Hepatitis () Others FDoyou submit your children (0-12 months). forimmunization?-f\l /A Name of Child Birthday Immunization — ki /A BCG DPT OPV AM 6. Do you practice family planning? Yes (yfo() ‘Method: Ino, why? H, Method of infant feeding: Breast () bottle () Mixed 1. Subjects you want to learn in health education: ‘Nutrition Drug abuse () it Family planning () Herbal plants () _ First aid measure () Scanned with CamScannerCOMMUNITY HEALTH ASSESSMENT FORM Respondent: NG ee pepe RS Stage: Relation to Head __ Head of re amily — (If not the Head on the Family) |. Family Data A. Head of the family: 2 ‘Ager Tossa B. Name of Spouse: D2Z Age: __64 __ C. Address: san Color city TelNo. D. Educational Attainment i, Husband: College _Godvote il, Wife: tollege Grande E. Length of Residency, = F, Ethnic Origin : ms G. Family: Nuclear () Extended (7 H, Religion: i 1. No, of Children: Z Bye ioere of tie Household: As Name Age Sex Status Education Occupation zm 30) cfs momcd. college Gvod. Deakist D1 HE, va Sagle. college Guo tall Coty Ayal zm 18 vn ‘sind Hig Schwn) a m We E in. gt Snool casa I Socio Economic Data ‘A, Source of Income ‘Occupation: ad eowner Husband: — Wife: aS Employed () Unemployed (7 ‘Self-employed () Monthly Income Below P 2,000 () 2,000 - P 5,000 () P 5,001 -P 8,000/F more than P 8,000 () B. Family Expenditures Food Below P 50() P50-75() More than P70 (f « 2. Clothing number of times of buying Once a year () Twice () Thrice a year () Q 3. Heuer iter 3 Telephone Flectichy (5 Student Activity Sheet 30 Scanned with CamScanner5. Others C. Housing and Environmental Condition ~ Conerete (fF , Wood () pest) Makeshift () Others Ventilation: Poor () Good (J- Lighting: “Adequate (J Inadequate () ‘Surroundings: leant) Dirty () ___B. Source of Water Supply __ oe af Artesian welll () Deep well () : NAWASA () Others: ~ . Storage of Drinking Water Refrigerated (7 Covered () Uncovered () - Containers used: Plastic () Clay jars () Bottles () Others: ee D, Toilet Facilities Sanitary: Flush (~ Bia g ann Owned Shared () Unsanitary: “Ballot” system () Others E. Garbage Dis} uf a “Collection () - Bur eee Open dumping () Garbage cans () Others : F, Food Storage Covered () Refrigerated (J Uncovered () G. Presence of Animals ‘Dogs (J Gats'() Pigs () Others Student Activity Sheet Scanned with CamScannerH, Backyard Gardening Vegetables ( Fruit-bearing (7 Others D. Community Resources ‘A. Health and Other Facilities Health center¢) Barangay hall Q~ ‘School (7 Church () Park () Market () Health center ()~ Private clinic () Public hospital () Private hospital () B. Indigenous health workers Trained “hilot” (} BHW{) y “Herbularyo” () Untrained *hilot” ( ) Others: C. Sources of health funds: Government () Private () NGOs/POs () Others: — E. Nutrition __.~A.-Food preference — - a — — Fish (7Fruits/ vegetables (}— Meat (— Mixed () B. Common Rice and egg (7 Rice and sardines () Rice and noodles (7 Others: C. Presence of Nutritional Disorder 1. Goiter Enlargement of the neck () Dysphagia () Hoarseness () Others: 2. Anemia Pallor() Easy fatigability () Body weakness () 3. Vitamin A deficiency E Night blindness () “Pilak sa mata” () Others 4. Others: F. Knowledge, Attitude and Practice ‘A. Do you utilize the health center: Yes () No wo Itno, why? Weve MS met B, Reason: Student Activity Sheet S5 Scanned with CamScannery So lmess() 3 lace aid can ena 0 Postnatal () Nutrition () 6. Fist Person consulted in times of iiness: ‘ Midwife () ‘wor “Herbularyo” ( ) BHW() Others D. Usual illness in the family What do you do for this condition? ‘Self. medication () Consultation () Hospital () Private clinics () Nursing () Others E. Others diseases TB () Leprosy () ‘Skin disease () Hepatitis () Others F..Do you submit your children (0-12 months) for immunization? Name of Child Birthday Immunization BCG DPT OPV AM . Do you practice family planning? Yes () No () Method: If no, why? H. Method of infant feeding: Breast () bottle () Mixed () 1. Subjects you want to learn in health education: Drug abuse () Nutrition = Family planning () Herbal plants (}~ ” > First aid measure ()~ Others Interviewed by:_pewere LATEX Date: _ceptuor qr psu Time: __S 312 9 Student Activity Sheet a2 Scanned with CamScannerStage Relation to Head 1 Tfnat the Heed of the Family |. Family Data . ‘A. Head of the family: Nive Vt) ____ 8. Name of Spouse: Lani} ran foe: C. Address: 4 |) a1 Vino" TelNo: M/A ese aimen i, Husband: ii. Wife: E Length of Residency: Susi Birla | bl yea) F. Ethnic Origin : WA G. Family: Nuclear (7 Extended () H. Religion: haptic I. No. of Children: J. Members of the Household: Education ‘Occupation Name Age Sex Status hsb. Fas ES} pot Reh anes a eeptyed Trempoyed () — Monthly Income Below P 2,000 () 2,000-P5,000() 5,001 - P 8,000 () more than P 8,000.() B. Family Expenditures 1. Food Below P50 () P50-75() More than 70() - 2. Clothing number of times of buying Once a year Thrice a year Twice () Water Telephone () Student Activity Sheet eee COMMUNITY HEALTH ASSESSMENT FORM " 3. Housing : eee 30 Scanned with CamScannereee 5S Public eee aa C. Housing and Environmental Condition A Home. Conore Wood () man Makoshit () others Ventilation. a Good () Lighting: ‘Adequate () Inadequate ( ) ‘Surroundings: ate birty B. Source of Water Supply a Artesian well () pocenely | NAWASA() Others: | i te a income oo Covered () Uncovered 0 . Containers used: Plastic () Clay jars (,) Bottles () Others: D. Toilet Facilities ‘Sanitary: Flush, Others ‘Shared () Unsanitary: “Ballot” system () Others E. Garbage Disposal Collection) Burying () Garbage cans () Others F. Food Storage _ Uncovered () Covered) Refrigerated () Pit privy () Owned () Buring () Open dumping () 7 yf Animals 6 sone ofa cats() Pigs () Others 31 Student Activity Sheet ca. ath Ta Se Scanned with CamScannerHt Backyard Gardening Vegetables () Frut-bearing () Others Herbal () | D. Community Resources | ’A. Health and Other Health center) School (J Park () Health conter () Public hospital () ities B. Indigenous health workers Trained “hilot °() BHW () “Herbularyo” () Others: . Sources of health funds: Government-¢J NGOs/POs () E Nutrition ‘A. Food preference Fish.¢) Fruits/ vegetables () Meat () B Common Rice and eg9 (? Rice and noodles () C. Presence of Nutritional Disorder 1. Goiter Enlargement of the neck () Hoarseness () 2, Anemia Palor () Body weakness () 3. Vitamin A deficiency - Night blindness () = Others 4. Others: F. Knowledge, Attitude and Practice ‘A. Do you utilize the health center: Y¢: if no, why? B. Reason: No() student Activity Sheet Untrained “hilot” ( ) Barangay hall() Church-( Market () \ Private clinic () Private hospital () er Private () | Others: \ Mixed-() Rice and sardines ( ) Others: Dysphagia () Others: Easy fatigability () “Pilak sa mata” () Scanned with CamScanneraaa ee _ Prenaial amily planning () Postnatal () Dental() “ Nutrition () . . First Person consulted in times of lines: MD.() Nurrse-(J— Midwife () “Hot” () “Herbularyo" () BHWO) Others D. Usual iliness in the family _/ What do you do for this condition? WS Sait modeation (} Consutaion () Hospita() Private cinios () Nursing () Others E Others diseases 7B () ‘Skin disease () Others Leprosy () Hepatitis () F. Do you submit your children (0-12 months). for immunization? Name of Child Birthday Immunization BCG DPT OPV AM G. Do you practice family planning? Yes (No () Method: Ino, why? H. Method of inf yeding: Breast bottle () Mixed ( 1. Subjects you want to Jear in health education: - Drug abuse (~~ ‘Nutrition (J = Family panning). 3 Herbal plants’ First aid measure ()~ Others student Activity Sheet Scanned with CamScannerMEET eer re GOMMUNITY HEALTH ‘ASSESSMENT FORM Respondent: MiG" oe: Relation to Head Head oF by famity (ifnot the Head of the Family) ~~ |. Family Data : A. Head ofthe femiy; WEG 0 Age: sg B. Name of Spouse: _F LS Age 0 C. Address: _Daqvpan_aty Tel No.:_——— a D. Educational Attainment i. Husband: ‘ raduate ji, Wife: E. Length of Residency: _c(vu, @ivia F. Ethnic Origin: _N/A G. Family: 4 Nuclear (4 Extended () H. Religion: |..No. of Children: 3 bb J. Members of the Household: 4 = Name Age Sex Status Education Occupation Wi 5G M waned High Gcnoo! Gg rq Wotlk! ef @. Z mae lord Hila celal Coad Sei Peta ric, BASS ee vie n T ; Ingit Callen — JA ra E = college So 4. Socio Economic Data A Occupation: Besareacecortee Husband: __Pray Wore, Wife: wi ‘Unemployed () ‘Self-employed, Below P 2,000 () 2,000 - P 5,000 ‘ , 5,000 ( ier ?8,000() more than ® 8.00067 1. Food Below P50 ere thane oe P50-75() 2. Clothing number of times of buyi Once ayear() wing ‘ Thrice a year () Twice | 3. Housing y Water (7 - {____ratephate Electricity 7 : Scanned with CamScannernA A Conerete () “Wood () Makeshift () Others Dees Good 4 io ents if Inadequate () Bog Dirty () "Deep weil () Others: Covered) ‘Scanned with CamScanner‘Scanned with CamScannerery A Prenatal () ae Family planning () Postnatal () Dental () Nutrition () C. First Person consulted in times of ines: MD. Nurse () Midwife () “Hilt” () “Herbularyo” () BHW() Others D. Usual illness in the family What do you do for this condition? Self- medication () Consultation () Hospital ( Private clinics () Nursing () Others: Others diseases 7B() Leprosy () ‘Skin disease () Hepatitis () Others F. Do you submit your children (0-12 months) for immunization? ‘Name of Child Birthday Immunization BCG DPT OPV AM G6 Sr Ge Oa alee aa ll tao, why? infant feeding: H. beta tet ing: sani FY Mixed () . in health education: ee Nuttin 4 Ee 0 Herbal plants (7 i Others le Oe as pa Vea Date:_sepr 26 ta) Time: $325 pm Scanned with CamScannerRespondent: Age: __ Stage Cerna ee yusente _____—— 048. Relation to Head — aed cmd tum (it not the Head of the Family) |. Family Data & Ne ot pune — ie —————— fg B Name of Spouse’ Age: exam WONNTAL , eodenenan Tal No.: . Educational Attainment eS ne atone KWo: wan cael dtadusit Length of Residency: __ rave E Ete Origin: yz —$—§ & Fem — ee N No. Ce a J. Members of the Household: £ tees Age Sex cal . Status Education Occupation tom a etch cone genre —i3— a cealot | cornnrry HEALTHT ASSESSMENT FORM N a tu tee — “ Dial, ete ean Bre Set Bt — tnt was ities. ecbamtare sah ie OO i uh Il. Socio Economic Data A. Sourge of income Occupation: Husband: Ze Wite: tee b Employed (J Unemployed f) Self-employed () Monthly income Below P 2,000 py 2,000- 5,000() 5,001 -8,000() more than P 8,000 () B. Family Expenditures 1. Food Below P50 () P50-75() More than P70 ( 2. Glothing number of ties of buying Once a year, ‘Twice () z Thrice a year ( ) ‘Housing 7 aor __Telephione () ‘Scanned with CamScanner— Ht Backyard Gardening N sdoatd Gan Herbal Fruit-bearing () Others D. Community Resources A Facil Health center, re les Barangay hall (f- School a Church Park () Market Health center Private clinic () Public hospital (f Private hospital () B. Indi bai Trained “hilot *() BHW () “Herbularyo" () Untrained “hot” () C. Sources of health funds: Government Ly" Private () NGOs/POs () Others: -— —A Food preference a _ - Fish Fruits/ vegetables (( Meat (7 Mixed () B. Common Rice and egg (y Rice and sardines () Rice and noodles (/ Others: C. Presence of Nutritional Disorder 1. Goiter Enlargement of the neck ( ) Dysphagia () Hoarseness () Others: 2. Anemia Pallor () Easy fatigability () Body weakness () 3. Vitamin A deficiency Night blindness () “Pilak sa mata” () Others 4. Others: Knowledge, Attitude and Practice ® A. Do you utilize the health conter: Yes (4/No () ino, why? B. Reason: ‘Scanned with CamScannerDirty () ‘Clean (f 8. Source of Water Supply _ eat Deap well() 'NAWASA Of Others: Storage of Drinking Water Refrigerated (7 Covered Lesvos () Containers iC Plastic (f'Clay jars (7f Bottles () Others: D, Todet Facitities: Sanitary , Pit privy ( Flush (¥° A ‘Shared () “Ballot” system () Others Garbane Disgaea! Collection a Burying () ‘Open dumping ( }) Garbage cans gf Others F ‘Covered () Uncovered () Rotrigeratod th 6 Boos Cats (f Pigs) Others ‘Scanned with CamScannertf eee. ; Prenaial () lanl Dental () ving () pee ) C. First Person consulted in times of iiness: MD. () Nurse Midwife () “plot” () “Herbularyo" () BHW() Others D. Usual ines in the family ‘What do you do for this condition? “ ‘Self. medication (Consultation ({ Hospital (7 Private clinics () Nursing () Others: E. Others diseases 7B () Leprosy () Skin disease () Hepatitis () Others F. Do you submit your children (0-12 months) for immunization? - Name of Child Birthday Immunization BCG DPT OPV AM G. Do you practice family planning? Yes () No() Method: Ifno, why? H. Method of infant feeding: Breast () bottle () Mixed () |. Subjects you want to leam in health education: ‘Drug abuse () Nutrition (i Family planning () Herbal plants (f First aid measure interviewed by:_Danille _c Viventt _-_ Date: D4. 27.902! Time: 3.00 por ‘Scanned with CamScannerCOMMUNITY HEALTH ASSESSMENT FORM Respondent: YL” _ _ Agi Stage: Se Relation toHead___Dolkur SSS not he Head of the Family) |. Family Data : ‘A. Head of the family: cs age: 4 B. Name of Spouse: Ie ay G. Address: JEU Cok pare) Tel No. vi D. Educational Attainment i. Husband: a ot ef it. Wife: E. Length of Residency: Sea. Bil. | F. Ethnic Origin : G. Family: Nuclear () Extended () H. Religion: __Calholie | No. of Children: J. Members of the Household: aT F ‘Wiest Ball Geka Folez A a E i kaa = TACT wD E “See Coleus: = Re © Tr Seat = Il. Socio Economic Data ‘A, Soutes of Income Occupation: Husband: ays =spmpe————— Wite: 5 Employed () ___ Unomployed () Sel-omployod Monthly Income Below P 2,000 () P-2,000-P 5,000() 5,001 -P6,000() more than P 8,000 B. Fasnily Expenditures 4. Food Bolaw f 30 () P50-75() More Wan P70)» 2, Clathing number of times of buying ‘Once a oat) Twico () Thrice a yee , Housin 3 HO tor bi evwcrewy of. Tolophano, Student Activity Sheet 3 ‘Scanned with CamScanner4. Schooing Public () 5. Others C. Housing and Environmental Condition A. Home Type Concrete Mixed () Others Ventilation. Poor () Lighting: Adequate f) Surouneges Clean B, Source of Water Supply “Artesian well () NAWASA () © Sta of Bika Water Refrigerated Uncovered () Containers used: Plastic () Clay jars (}) Bottles D. Toilet Facilities Sanitary Flush Others Shared () Unsanitary: “Ballot” system ( ) Others E. Garbage Dis, ut . Collection Burying () Garbage cans () Others F. Food Storage Covered () Refrigerated (/ G. Pxsnnoglo annals Dogs Pigs () Private () Wood () Makeshift () Good 6” Inadequate () Dirty () Deep weil () Others: Own ute Wipe fe pe Covered () di Others: Pit privy () Owned () Buming () Open dumping () Uncovered () Cats J Others. student Activity Sheet an ‘Scanned with CamScanner~ A Backyard ¢ Vegetables Fruit-bearing () Others NONE D. Community Resources A Health and Othgr Facilities Health cepter (4 School Park () Health center () Public hospital b B, Indigenous health workers Trained “hilot *() BHV/ (f “Herbularyo" () ©. Sources of health fund: Government {) NGOs/POs 4 E Nutrition 5, Others ¢ Housing and Environmental ‘A. Home. Type Concrete () Mixed () Others ventilation: Poor () Lighting: ‘Adequate ‘Surroundings: Clean ( 8 Source of Water Supply. — “Artesian wel () NAWASA (7 Refrigerated ( Uncovered () Oe oad! Contains vay jars () Bottles () others: D. Tollet Facilities ‘Sanitary Flush () Others ‘Shared () Unsanitary: “Ballot” system () Others = Di Collection () Burying () Garbage cans () Others F. Food Stofage ‘Covered () Refrigerated () G. Presence of Animals Dogs (9 Pigs () Sheet Condition Wood () Makeshift () Good () Inadequate () Dirty () Deep well () Others: Covered () Pit privy () owned () Buming ( Open dumping () Uncovered () Cats () ‘Others. 31 Scanned with CamScanneree my i Backyard Gardening tables () Frubearng () Oters . Community Resources erangay hal a A fat canter Church (3 olf) Market () Eee Private cit!” ( Seat Private hospital () Public hospital () B. tndigsnous health worers e Trained “hilot "() BHW, Untrained “hilot" ( ) “Herbularyo"() be e Suseel cee Private () ‘Government () Others: NGOs/POs () E. Nutrition 1 me - Fah) Puts vegetebes() : Fish () Fruits/ vege! eat Mixed-() 8. Common. - we ‘ Rice and sardines (/ Rice and egg () Rice and noodles () ones C. Presence of Nutritional Disorder 1. Goter Enlargement of the neck () Dysphagia () Hoarseness () Others: 2. Anemia Pallor() Easy fatigabitty () Body weakness () 43. Vitamin A deficiency Night blindness () “Pilak sa mata” () Attitude and Practice uti Scanned with CamScanner_luidite () ‘Herbularyo"() Others . Usual lines in the ta my tes What do you do for this condition? ‘Sel medication () Consultation () Hospital () Prato cinies () Nursing () Others & Others diseases so Leprosy () in disease () Hepattts () Others Do you submit your children (0-12 months) for immunization? per ‘Name of Child Birthday Immunization BCG DPT OPV AM Do you practice family planning? Yes () No () Method: Hfno, why? H, Method of infant feeding: Breast () bottle () Mixed () 1. Subjects you want to learn in health education: Drug abuse (f ‘Nutrition () Family planning () Herbal plants () First aid measure () Others: Interviewed by:__Sliege Heel S__-_ Time see Dale ee Scanned with CamScanner