Family no.____ H.C.

____ COMMUNITY SURVEY FORM Length of residency ___50YRS___

No. _____
Religion: INC Place of origin __________ District No.:___III DISTRICT_______
Father: ESTRELLA, REYNALDO BAYACAL
Religion: INC Place of origin __________ Other members of household: ___3_____
Mother: ESTRELLA, CEFERINA TIBONG
Purok No.______ Brgy No.179_____ Zone No._____
Address______________________________________ Living__9____ Dead_______ Abortion_______

Data on Family: No. of children

Republic of the Philippines Date Surveyed_SEPT 24 2022___________

Metro Manila HOME
HEALTH OPERATION CENTER Length of residency__50YRS_____ A) Type of building (uri ng bahay)
Immunization for last 5 yrs. Cases
Names Date Agp Sex Civil Relationship Education Occupation Income BC DP OP Measle Tetanus AP PP TB FP Mentall Malnourished Drug Others
of e Status to the Head G T V s Toxoid y abuser
birth of the Retarted
Family
NERISSA E. JAN 48 F MARRIED DAUGHTER COLLEGE CAREGIVER 80K
17 GRAD.
LIM
1974
ROWENA DEC 46 FF MARRIED DAUGHTER COLLEGE HOUSEMAID 30K
GUZMANOS 12 GRAD
1976
MIRIAM DEC 44 F SINGLE DAUGHTER COLLEGE PHARMACIST 40K
ESTRELLA 12
1978
CHERYL OCT 40 F SINGLE DAUGHTER COLLEGE NURSE 90K
ESTRELLA 25 GRAD
1982
AMOR FEB 38 F MARRIED DAUGHTER COLLEGE CALL 40K
ZAPATA 4 CENTER
1984
CHARMAIN SEPT 28 F SINGLE DAUGHTER COLLEGE N/A 20K
E ESTRELLA 1 GRAD
1994
MARK NOV 27 M SINGLE SON COLLEGE 10K
ANGEL 11
ESTRELLA 1995
 Strong ( / ) Light ( ) A.)Source(pinanggagalingan) (Iba pang impormasyon kaugnay sa kalusugan ng pamilya)
(matibay) (Magaan) Private(Pribado) (/) A.)Food storage(Pag-iimbak ng pagkain)
Public(Publiko) ( ) Covered(Nakatakip (/)
Mixed ( ) Makeshift ( ) 1.)Pipe(Tubo) ( ) Uncovered(Walang takip) ( )
(Magkahalo) (Pangsamantala) 2.)Hose(hos) ( ) B.)Type of infant feeding(0-2yrs) ( )
3.)Pail(Timba) ( ) (Uri ng pagpapakain)
B) General Sanitary Condition 4.)Other(Iba pa) ( ) Breastfeeding(pagpapasuso) (/ )
(kalahating lagay ng kalinisan) Aritificial(Artipisyal/do natural)( )
Good (/ ) Light ( ) Poor( ) B.)Drinking water storage C.)Type of Artificial Feeding
(Mahusay) (Katamtaman) (Di mabuti) (Pag-iimbak ng tubig) Condensed(Malapot) ( )
Covered)Nakatakip (/ ) Evaporated(Malabnaw) (/ )
C) Excretal Disposal ( Pagtatapon ng dumi) Uncovered(walang takip) ( ) Powdered(Pulbos) ( )
Sewage (A;kantariliya) ( ) 1.)Can(Lata) ( ) D.)Food supplements given to babies
Septic Tank (/ ) 2.)Drum(Dram) ( ) (Karagdagang pagkain na binibigay sa sanggol)
Water sealed ( ) 3.)Bottle(Bote) ( ) Plain(Lugar) ( )
Public Comfort Room (palikuran) ( ) 4.)Faucet(Gripo) ( ) Mashed yellow fruites and vegetables ( / )
Others, Specify (Iba pa, tukuyin) ( ) 5.)Others(Iba pa) ( ) (Dilaw na prutas at gulay) (/)
Egg(Itlog) ( )
D) Backyard Gardening (Halaman sa likod ng bahay GARBAGE DISPOSAL Flake fish,meat,chicken ( )
Vegatable (Gulay) ( ) A.)Method of Disposal (Manipis na piraso ng isda,karne,manok)( )
Ornamental(Palamuti/dekorasyon)( / ) (Pagtatapong ng Basura) FAMILY PLANNING
Fruit tree (Punong namumunga)( ) DPS collection(pangongolekta ng DPS) (/ ) Acceptor ( )
Others (Iba pa) ( ) Burning(Pagsunog) ( )
None (Wala na) ( ) Dumping(pagtatambak) ( )
What method? _______________
Burying(Pagbabaon) ( ) Non Acceptor (/)
COMMUNICABLE DISEASE Recycling ( ) Why? _________________
No. of TB cases ________ Others(Iba pa) ( ) Source of information of FP:
No. of Leprosy ________ HC ( ) Mass media ( )
Under treatment (X ) DENTAL SOURCE
Where?_______________ A.)Health Center ( )
Hospital ( / ) Others,specify: ( )
Not under treatment ( ) B.)Hospital ( ) Neighbor ( ) ______________
SOURCE OF HEALTHCARE(PAGAMUTAN) C.)Private ( ) SURVEYED BY:_______________________
A.) Health Center ( ) D.)Industrial Dentist (/) (NAME)
B.) Hospital (/ ) E.)Others ( ) ______________________
C.) Private ( )
D.) Others ( )
(DESIGNATION)

WATER SUPPLY OTHER INFORMATION RELATED TO FAMILY HEALTH