Professional Documents
Culture Documents
V. ECONOMIC PROFILE
32. Source of Income and Assistance (Check all applicable)
1 Own earnings, salary / wages 2 Own Pension 3 Stocks / Dividends
4 Dependent on children / relatives 5 Spouse's salary 6 Insurance
7 Spouse's Pension 8 Rentals / sharecrops 9 Savings
10 Livestock / orchard / farm 11 Fishing 12 Other, specify
33.A Assets: Real and Immovable Properties (Check all applicable) 33.B Assets: Personal and Movable Properties
1 House 2 Lot / Farmland 3 House & Lot Automobile Personal Computer Boats
4 Commercial Building 5 Fishpond / resort Heavy Equipment Laptops Drones
6 Others, specify Motorcycle Mobile Phones Specify
34. Monthly Income (in Philippine Peso) 35.A Problems / Needs Commonly Encountered (Check all applicable)
60,000 and above 50,000 to 60,000 40,000 to 50,000 35.A Economic
30,000 to 40,000 20,000 to 30,000 10,000 to 20,000 1 Lack of income / resources
5,000 to 10,000 1,000 to 5,000 Below 1,000 2 Loss of income / resources
3 Skills / capability training (specify)
4 Livelihood opportunities (specify)
5 Others, specify
V. HEALTH PROFILE
36.A Medical Concern 36.D Aural
Blood Type: O A B Aural impairment
Physical Disability (specify): Others
Health problems / ailments 36.E Social / Emotional
Hypertension Arthritis / Gout Coronary Heart Disease Feeling neglect / rejection
Diabetes Chronic Kidney Disease Feeling neglect / rejection
Alzheimer's / Dementia Feeling helplessness / worthlessness
Chronic Obstructive Pulmonary Disease Feeling loneliness / isolate
Others, pls specify Lack leisure / recreational activities
36.B Dental Concern Lack SC friendly environment
Needs Dental Care Others, specify
Others 36.F Area / Difficulty
36.C Optical High Cost of medicines
Eye impairment Lack of medicines
Needs eye care Lack of medical attention
Others Others
37. List of Medicines for Maintenance
This certifies that I have willingly given my personal consent and willfully participated in the provision of data and relevant information
regarding my person, being part of the establishment of database of Senior Citizens.
_______________________________
Name and Signature of Senior Citizen
Right Thumb Print of Senior Citizen
__________________________________ ________________________
Name and Signature of Assisting Person 1 Relationship to Senior Citizen
__________________________________ ________________________
Name and Signature of Assisting Person 2 Relationship to Senior Citizen
_________________________________ ________________________
Name of Signature of Interviewer/Verifier Organization/Office