IV.

DEPENDENCY PROFILE
30. Living/Residing with (check all applicable) 31. Household Condition
Alone Grand Child(ren) Common Law No privacy Overcrowded in home
Spouse
Spouse In-law(s) Care Institution Informal Settler No permanent house
Child(ren) Relative(s) Friend(s) High cost of rent Longing for independent living quiet
atmosphere
Others, pls Others, specify
specify
V. ECONOMIC
PROFILE
32. Source of IncomeAssistance (Check all ble)
and applica
Own earnings, / wages Own Pension Stocks / Dividends
salary
Dependent onn / relatives Spouse's salary Insurance
childre
Spouse's Rentals / Savings
Pension sharecrops
Livestock /arm Fishing Other, specify
orchard / f
33. Assets: Real andovable Properties applicable) 34. Assets: Personal ovable Properties
Imm (Check all and M
House Lot / House & Lot Automobile Personal Boats
Farmland Computer

Commercial g Fishpond / resort Heavy Equipment Laptops Drones

Buildin
Others, specify Motorcycle Mobile Phones Specify

35. Monthly Income ippine Peso)

(in Phil
60,000 and 50,000 to 60,000 40,000 to 50,000 36. Problems / Needs monly Encountered (Check all applicable)
above Com
30,000 to 40,000 20,000 to 30,000 10,000 to 20,000 Lack of income /es
resourc
5,000 to 10,000 1,000 to 5,000 Below 1,000 Loss of income /es
resourc
Skills / capability (specify)
training
Livelihood(specify)
opportunities
Others, specify
VI. HEALTH PROFILE

37. Medical Concern 40. Hearing

Blood Type: O A AB Don't know Aural impairment/ g impairment

B Hearin
Physical Disability (specify): Others

Health problems / ailments 41. Social /

Emotional
Hypertension Arthritis / Gout Coronary Heart Feeling neglect /
Disease rejection
Diabetes Chronic Kidney Disease Feelingorthlessness
helplessness / w
Alzheimer's / Dementia Feeling loneliness / e
isolat
Chronic Obstructive Pulmonary Disease Lack leisure / l activities
recreationa
Others, pls specify Lack SC friendly ment
environ
38. Dental Concern Others, specify

Needs Dental Care

Others 42. Area / Difficulty

39. Optical High Cost of

medicines
Eye impairment Lack of medicines

Needs eye care Lack of medical

attention
Others Others

43. List of Medicines for Maintenance

44. Do you have a scheduled medical/physical Yes No
check-up?
45. If Yes, when is it done? Yearly Every 6 months Others

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 and

Signature of Interviewer/Verifier Organization/Office

Date of Interview: __________________________________

Place of Interview: __________________________________

THIS FORM IS NOT FOR

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