G22A-Interview-Tool-with-answer (2) (Repaired)

Pamantasan ng Lungsod ng Marikina
2 Brazil St., Greenheights Subd., Concepcion Uno, Marikina City

College of Health Sciences
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DEMOGRAPHIC PROFILE
Pangalan Position in Edad Kasarian Lugar ng Civil Relihiyon Educational Trabaho Language Nationality Weight Height
the Family Kapanganakan Status Status Spoken (or and or
According Dialect) Ethnicity (if
to Rank applicable)
1. Editha Sanchez M 30 F Antique M Catholic College House Filipino Filipino 75 kg 5’3

under keeper
Grad.
2. Omar Sanchez F 42 M Paco M Catholic Highscho Kitchen Filipino Filipino 86 kg 5’8

ol Staff
3. Migs Sanchez C 7 M Quezon City S Catholic Grade 2 - Filipino Filipino 27 kg 121 cm
4. Tamara Sanchez C 3 F Marikina City S Catholic - - Filipino Filipino 15 kg
5.
6.
7.
Primary Source of Income Omar Sanchez (Father)

(Pangunahing pinagmumulan ng kita)
NCM113: COMMUNITY HEALTH NURSING 2 - RELATED LEARNING EXPERIENCE DATA COLLECTION TOOL Page 1 out of 46
Other Sources of Income None

(Ibang pinagmumulan ng kita)
Combined Family Income per Month 14,000

(Pinagsamang kita ng pamilya kada buwan)
Home Address #149 Sitaw st., Libis Bulelak Malanday Marikina City
(Tirahan)
Informant Name and Contact Number 09103560609

(Pangalan ng nakapanayam at numero)
Interviewed By Franz Isaiah Fabillar

(Nakapanayam ni)
Legend
Position in the Family According to Rank (F) Father (Tatay) (M) Mother (Nanay) (1) Eldest (Panganay) (2) Second (Pangalawa) (3) Third
(Posisyon sa pamilya ayon sa kaayusan) (Pangatlo)
Sex (Kasarian) M) Male (lalaki) (F) Female (babae)
Civil Status (S) Single (M) Married (kasal) (W) Widow (biyuda) (SP) Separated (hiwalay)
(Katayuang sibil)
(LI) Live-in (May kinakasama)
Educational Attainment (NFE) No Formal Education (V) Vocational (EL) Elementary Level (EG) Elementary Graduate
(Antas ng pinag-aralan)
(HL) High School Level (HG) High School Graduate (CL) College Level (CG) College Graduate
SOCIO-ECONOMIC AND CULTURAL VARIABLES
A. SOCIAL INDICATORS
Place of Residence (Lugar Kung Saan Nakatira)
How long has your family been living in the ● Less than a year (Hindi aabot ng isang taon)
said community? ● 1 - 3 years (Isa hanggang tatlong taon)
● 5 - 7 years (Lima hanggang pitong taon)
Gaano na katagal naninirahan ang inyong
● 8 years and above (Walong taon at pataas)
pamilya sa Barangay ____.
What kind of neighborhood is your home ● Village

located in? ● Subdivision
● Compound
Sa anong uri ng kapitbahayan matatagpuan ● Others, please specify: __________ (Iba pa, pakitukoy)
ang inyong tirahan?
Does your family experience any conflict ● Always (Palagi)

within your neighborhood or community? ● Often (Madalas)
● Sometimes (Minsan)
Nakakaranas ba ang iyong pamilya ng
● Never (Hindi kailanman)
anumang salungatan sa loob ng iyong
kapitbahayan o komunidad?
Housing
What is the property that you are currently ● Owned (Pagmamay-ari)

living in? ● Rented (Inuupahan)
● Others, please specify: __________ (Iba pa, pakitukoy)
Anong ari-arian ang inyong kasalukuyang
tinitirahan?
What type of housing do you have? ● Multi-story house (Maraming palapag na bahay)
● Bungalow (One-story house) (Isang palapag na bahay)
Anong uri ng tirahan ang mayroon ka? ● Townhouse
● Condominium
● Apartment
Note: Provide the choices
How many people are living in the house? ● 1 - 3 (Isa hanggang tatlo)
● 4 - 6 (Apat hanggang anim)
Ilang katao ang naninirahan sa inyong bahay? ● 7 and above (Pito o pataas)
How many rooms do you have in your ● 1 - 2 (Isa hanggang dalawa)

house? ● 3 - 4 (Tatlo hanggang apat)
● 5 - 6 (Lima hanggang anim)
Ilang silid ang mayroon sa iyong tahanan? ● More than 6 (Mahigit sa anim)
How many people share rooms? ● 2 people (Dalawang tao)
● 3 people (Tatlong tao)

Ilang tao ang naghahati sa silid? ● More than 3 people (Mahigit tatlong tao)
How many windows are there in your

house?
Living Room Kitchen (Kusina) Dining Room Bedroom 1 Bedroom 2
(Sala) (Kainan) (Kwarto 1) (Kwarto 1)
Ilang bintana ang mayroon sa iyong tahanan?
● 1-3 ● 1-3 ● 1-3 ● 1-3 ● 1-3
(Isa (Isa (Isa (Isa (Isa
hanggang hanggang hanggang hanggang hanggang
tatlo) tatlo) tatlo) tatlo) tatlo)
● 4-6 ● 4-6 ● 4-6 ● 4-6 ● 4-6
(Apat (Apat (Apat (Apat (Apat
hanggang hanggang hanggang hanggang hanggang
anim) anim) anim) anim) anim)
● 7 or more ● 7 or more ● 7 or more ● 7 or more ● 7 or more
(Pito o (Pito o (Pito o (Pito o (Pito o
higit pa) higit pa) higit pa) higit pa) higit pa)
Sanitation
How often do you clean your house? ● Daily (Araw-araw)

● 3 times a week (Tatlong beses sa isang linggo)
(Gaano kadalas linisin ang iyong tirahan) ● Once a week (Isang beses sa isang linggo isang beses sa isang linggo)
3 times a week ● Every two weeks (Isang beses sa dalawang linggo)
What type of drainage system does the ● Natural (Rivers, Streams) (Natural - Ilog, Batis)
family and their community have? ● Manmade (e.g. Canal, Septic Tank) (Ginawa ng tao - Kanal, Septic Tank)
(Anong klaseng sistema ng paagusan ang
mayroon sa iyong pamilya at pamayanan?)
Manmade
Do you maintain and check your drainage ● Daily (Araw-araw)

system in your house? ● 3 times a week (Tatlong beses sa isang linggo)
● Once a week (Isang beses sa isang linggo)
(Nasusuri ba nang regular ang sistemang ● Every two weeks (Isang beses sa dalawang linggo)
paagusan sa iyong tahanan?) ● Never (Hindi kailanman)
Never
Do you have a toilet with a flush? ● With (Meron)

● Without (Wala)
(Mayroon ka bang palikuran na may flush?) ● Others, please specify: __________ (Iba pa, pakitukoy)
With
Vectors
Is there a presence of pests (e.g., ● With (Meron)

cockroaches and rats) in your home? ● Without (Wala)
(Mayroon bang presensya ng peste, ipis, at

daga sa iyong tahanan?)
If yes, what type of pests do you usually see ● Cockroaches (Ipis)

in your house or community? ● Rats (Daga)
● Mosquitoes (Lamok)
(Kung oo, anong klaseng peste ang iyong ● Flies (Langaw)
nakikita sa iyong tahanan o pamayanan? ● Others, please specify: __Anay__ (Iba pa, pakitukoy)
What are the breeding sites that are found in

your house or community?
Breeding Site Check all that applies
(Piliin ang lahat ng pwede)
(Ano ang mga breeding site na matatagpuan sa
iyong bahay o komunidad?) Cockroaches Flies Rats Mosquitoes Others:
(Ipis) (Langaw) (Daga) (Lamok) (Iba Pa)
Holes (Mga butas o ● ●

puwang)
Cabinet (Kabinet)
Garbage ● ● ● ● ●
(Basurahan)
Dumpsite (Imbakan) ● ● ● ● ●
Ceiling (Kisame)
Below the stairs ● ●

(Ilalim ng Hagdan)
Others, please
specify: __________
(Iba pa, pakitukoy)
What are your ways to control them? Check all that applies (Piliin ang lahat ng puwede): (Piliin ang lahat ng pwede)
(Ano ang iyong mga paraan upang kontrolin ● Insecticide (Insektisaid)
ito?) ● Mosquito coil (Katol)
● Bed Nets (Kulambo)
● Fumigation (Pagpapausok)
● Ignition (Pagsisiga)
● Others, please specify: _Off lotion_ (Iba pa, pakitukoy)
Do you have any domestic animals in your ● Yes (Oo)

house? If yes, specify: (Kung oo, anu-ano ang mga ito)
(Mayroon ka bang mga alagang hayop sa iyong ● Cat (Pusa)
bahay? ● Dog (Aso)
● Hamster
● Rabbit (Kuneho)
● No (Hindi)
Do you have domestic animals at home?

How are they kept?
Animal Tied/Caged Free to go anywhere
(Mayroon ka bang mga alagang hayop sa
bahay? Paano sila pinananatili?) Cat (Pusa) ● ●
Dog (Aso) ● ●
Hamster ● ●
Rabbit (Kuneho) ● ●
Others, please specify: ● ●

__________ (Iba pa, pakitukoy)
Are they vaccinated?

(Nabakunahan ba sila?)
Animals Vaccinated Not Vaccinated
Cat (Pusa) ● ●
Dog (Aso) ● ●
Hamster ● ●
Rabbit (Kuneho) ● ●
Others, please specify: ● ●

__________ (Iba pa,
pakitukoy)
Availability of Social and Health Facilities
What kind of healthcare facility is near your ● Clinics (Mga klinika)

house? ● Public Hospital (Pampublikong Ospital)
(Anong uri ng pasilidad ng pangangalagang ● Private Hospital (Pribadong Ospital)
pangkalusugan ang malapit sa iyong bahay?) ● Barangay Health Center
How far is it from your house? ● Walking distance (Kayang lakarin)

(Gaano kalayo ito mula sa iyong bahay?) ● 1 ride (Isang sakay)
● 2 - 3 rides (Dalawa hanggang tatlong sakay)
● 4 or more rides (Apat o mahigit na sakay)
● 1 km and below (Isang kilometro at kumulang)
● 1 km and above (Isang kilometro at mahigit)
In case of emergencies, where do you ● Clinics (Mga klinika)

usually go first for healthcare services? ● Public Hospital (Pampublikong Ospital)
(Sa kaso ng mga emerhensiya, saan ka ● Private Hospital (Pribadong Ospital)
kadalasang unang pumunta para sa mga ● Barangay Health Center
serbisyo sa pangangalagang pangkalusugan?) ● Herb Doctors (Mga Albularyo)
NOTE: (Interviewer) Recite the choices
Does your local barangay office have a clinic ● Yes (Oo)

available for all barangay residents? ● No (Hindi)
(May klinika ba ang inyong lokal na tanggapan ● Others, please specify: __________ (Iba pa, pakitukoy)
ng barangay para sa lahat ng residente ng
barangay?)
Availability of Communication and Transportation Facilities
Do you have an internet connection at ● With (Meron)

home? ● Without (Wala)
(Mayroon ba kayong internet connection sa

inyong bahay?)
How often do you lose network signals in ● Daily (Araw-araw)

your area? ● 3 times a week (Tatlong beses sa isang linggo)
● Once a week (Isang beses sa isang linggo)
Gaano kadalas mawala ang network signals sa ● Every two weeks (Isang beses sa dalawang linggo)
inyong lugar? ● Never (Hindi kailanman)
What is your usual mode of transportation? ● Train (MRT, LRT)

● Tricycle
(Ano ang inyong kadalasang sinasakyang ● Bus
transportasyon?) ● Jeep
● Taxi
● Grab
● Service
● Private (Own car) (Pribado - Sariling sasakyan)
Social Organizations
Do you belong in any organization that is related to

community health?
Name of YES If yes, name the What do you usually do NO
Family (Oo) organization and what is it for? (Hindi)
*Church, Environmental & Government Org Member (Kung oo, anong (Ano po ang usual niyong
organisasyon?) ginagawa and para saan?)
(Kabilang ka ba sa anumang organisasyon na may
kaugnayan sa kalusugan ng komunidad?) Editha ● ●
Omar ● ●
Migs ● ●
Tamara ● ●
Have you participated in seminars or projects related to

promoting the health of the community?
NAME OF FAMILY YES (Oo) NO (Hindi) IN OFFICE
MEMBER SEMINARS
Nakilahok ka na ba sa programa o proyekto na mayroong
kaugnayan sa pagpapaigting ng kalusugan sa inyong Editha ● ● ●
komunidad?
Omar ● ● ●
Migs ● ● ●
Tamara ● ● ●
Relationship to Larger Communities
Do you participate in your neighborhood’s associations ● Yes (Oo)

such as the Homeowner’s Association? ● No (Hindi)
Nakikilahok ka ba sa ososasyon ng inyong lugar katulad ng

Homeowner's Association?
Are you involved in any of the services of your ● Yes (Oo)

Sangguniang Barangay? ● No (Hindi)
Ikaw ba ay napapabilang sa mga serbisyo ng iyong

Sangguniang Barangay?
Are you willing to partake in outreach activities your ● Yes (Oo)

barangay holds when it comes to community health ● No (Hindi)
and sanitation?
Ikaw ba ay pumapayag na makilahok sa aktibidad na

isinasagawa ng inyong barangay na mayroong kaugnayan
sa kalusugan at kalinisan ng inyong komunidad?
Are you willing to take part or volunteer in activities ● Yes (Oo)

launched by the DOH? ● No (Hindi)
Ikaw ba ay pumapayag na makilahok o mag boluntaryo sa

aktibidad na isinasagawa ng DOH?
B. ECONOMIC INDICATORS
Income and Expenses
What is the estimated range of your monthly

income? Or weekly
Name of ₱10,957 - ₱21,914 - ₱43,828 - ₱76,669 - ₱131,483 - ₱219,140 SOCIAL
( Magkano po ang tinatayang buwanag sweldo o kita Family ₱21,914 ₱43,828 ₱76,669 ₱131,484 ₱219,140 and above CLASS BY
ng inyong pamilya?) Member INCOME
Editha ● ● ● ● ● ●
Social Classes by Income Levels:
Omar ● ● ● ● ● ●
Legend:
(LINP) Low income but not poor > ₱10,957 - ₱21,914 Migs ● ● ● ● ● ● 500-
(LM) Lower middle class > ₱21,914 - ₱43,828 1000
(M) Middle class > ₱43,828 - ₱76,669
(UM) Upper middle > ₱76,669 - ₱131,484 Tamara ● ● ● ● ● ● 500-
(UNR) Upper but not rich > ₱131,483 - ₱219,140 1000
(R) Rich > ₱219,140 and above
● ● ● ● ● ●
What is the estimated range of your monthly

expenses in your family? Or weekly Name of ₱1,000 and ₱1,000 - ₱5,000 ₱5,000 - ₱8,000 ₱8,000 - ₱12,000 - ₱15,000 and
Family Member below ₱12,000 ₱15,000 above
(Magkano po ang nagagastos niyo sa isang buwan?)
Editha ● ● ● ● ● ●
Omar ● ● ● ● ● ●
● ● ● ● ● ●
● ● ● ● ● ●
● ● ● ● ● ●
Does your daily income meet the needs of your ● Always (Palagi)
family everyday? ● Sometimes (Minsan)
(Natutugunan o sapat po ba ang inyong pang-araw- ● Never (Hindi kailanman)
araw na kita sa mga pangangailoangan ng inyong
pamilya araw-araw?)
Who is in charge of managing the money in the ● Mother (Nanay)

family? ● Father (Tatay)
(Sino ang nagbubudget ng pera sa inyong pamilya?) ● Both parents (Parehong magulang)
What are the top priorities when spending money ● Food (Pagkain)
for the family? ● Education (Edukasyon)
(Ano ang mga pangunahing bagay na iyong binibili ● Medication (Gamot o Maintenance)
para sa inyong pamilya?) ● Leisure and Travel (Paglilibang at Paglalakbay)
● Utility Bills (Bayarin sa Kuryente, Tubig, Cable, Internet atbp.)
● Shelter (Renta ng Bahay)
● Others, please specify): _____________ (Iba pa, pakitukoy)
Do you get any financial assistance or support ● Yes, I have (Oo, meron)
services for any of your daily needs? ● No, I don’t have (Hindi, wala)
(Mayroon o nakakatanggap ba kayo ng tulong ● Sometimes
pinansyal o mga suporta para sa inyong mga gastusin
pang araw-araw?)
If yes, what type of financial assistance or support ● 4Ps or other government assistance programs
services? ● Allowance from other family members (Padala mula sa ibang kamag-anak)
(Kung oo, anong klaseng tulong pinansyal or suporta ● Others, please specify): _____________ (Iba pa, pakitukoy)
ito?)
Do you have health insurance? ● With (Meron)

(Mayroon ba kayong health insurance?) ● Without (Wala)
If yes, what type of health insurance did you invest ● PhilHealth

in? ● Health Maintenance Organizations (HMOs)
(Kung oo, anong klaseng health insurance ang iyong ● Others (please specify): __________ (Iba pa, pakitukoy)
pinamuhunan?)
C. ENVIRONMENTAL INDICATORS
Physical Characteristics of the Community
What kind of city do you reside in? ● Urban (Lungsod)

(Anong klase ng bayan ka nananatili?) ● Rural (Sa probinsya / bukid / barrio)
Are you aware of any environmental hazards ● Yes (Oo)

within your community? If yes, what are those environmental hazards? (Select all that apply)
(May kamalayan kaba sa mga panganib sa loob ng (Kung oo, ano ‘yong mga panganib sa kapaligiran? - Piliin ang lahat ng pwede)
iyong pamayanan?) ● Floods (Mga Baha)
● Volcanic Eruption (Pagsabog ng Bulkan)
● Landslide (Pagguho ng Lupa)
● Factory (Pabrika)
● No (Hindi)
Do you live close to any body of water such as ● Yes (Oo)

rivers and lakes? ● No (Hindi)
(Nakatira kaba sa mga lugar na malapit sa anyong
tubig katulad ng ilog at lawa?)
What is the usual weather in your community? ● Sunny (Maaraw)

(Ano ang kadalasang panahon sa iyong ● Rainy (Maulan)
pamayanan?)
Is there visible trash and litter in your area? ● Yes (Oo)

(Mayroon bang nakikitang basura at kalat sa iyong ● No (Hindi)
pamayanan?)
Water Supply
What is your water supply in your house? ● Manila Water

(Ano ang iyong suplay ng tubig sa iyong tahanan?) ● Maynilad
● Deep well (Balon)
● Groundwater (Tubig poso)
● River (Ilog)
How often do you experience interruptions in ● Daily (Araw-araw)

your water supply? ● 3x a week (3 beses sa isang linggo)
(Gaano kadalas mo nararanasan na mawalan ng ● Once a week (Isang beses sa isang linggo)
suplay ng tubig?) ● Every two weeks (Isang beses sa dalawang linggo)
What type of water does your family drink? ● Commercially-Prepared Water (Mineral water, Distilled water, Purified water)
(Anong klaseng tubig ang iniinom ng iyong ● Tap water (Tubig sa gripo)
pamilya?) ● Others, please specify: __________ (Iba pa, pakitukoy)
Waste Disposal
Do you practice proper segregation ● Yes (Oo)

(Biodegradable, Non-Biodegradable and ● No (Hindi)
Recyclable)?
(Ginagawa mo ba ang tamang paghihiwalay ng

basura?)
(Nabubulok, Di- Nabubulok, Recycable)
Do you have any covers for your garbage bins? ● With (Meron)
(May takip ba ang iyong mga basurahan? ● Without (Wala)
How often in a week do you dispose of your ● Everyday (Araw-araw)

trash/garbage? ● Every other day (Tuwing makalawa)
(Gaano kadalas mo itinatapon ang iyong basura?) ● Once a week (Isang beses sa isang linggo)
● Twice a week (Dalawang beses sa isang linggo)
● Others, please specify: __3 times__ (Iba pa, pakitukoy)
D. CULTURAL FACTORS
Religion
Do you have any religious

practices that you strictly
follow? NAME OF FAMILY FATHER MOTHER CHILD 1 CHILD 2 CHILD 3 OTHER/S:
MEMBER
(Mayroon ba kayong relehiyosong
Avoiding certain ● ● ● ● ● ●
gawain na mahigpit niyong
sinusunod?) foods/diet restrictions
(Bawal na pagkain/sa diet)
Clothing ● ● ● ● ● ●
restrictions/dress code
(Uri ng pananamit)
Restrictions related to ● ● ● ● ● ●
receiving blood or blood
products
(Bawal tumanggap o mag-
donate ng dugo sa iba)
Going to church every ● ● ● ● ● ●

sunday
(Pagpunta sa simbahan
tuwing linggo)
None (Wala) ● ● ● ● ● ●
Others (please specify):

___________ (Iba pa,
pakitukoy)
Cultural Beliefs and Practices that affect Health
What is your approach in a certain situation ● Self-medication (Ginagamot ang sarili)

when one of the family gets sick? ● Consult to doctor (Papacheck up o kumokonsulta sa doctor)
● Forget about it (Hinahayaan na lang)
(Ano ang iyong ginagawa o pag puna sa isang ● Consult to herb doctor (Nagpapakonsulta sa albularyo)
sitwasyon kapag ang isa sa iyong pamilya ay nagka ● Search the answer in social media (Naghahanap ng sagot sa google, youtube, tiktok)
sakit?) ● Pray (Dinadasalan lamang)
● Go to health center (Pumupunta sa health center)
● Others (please specify): ___________ (Iba pa, pakitukoy)
What kind of herbal medications do you usually ● Sage (Sambong)

use when someone is sick? ● Bitter Gourd (Ampalaya)
● Wild Tea (Tsaang gubat)
(Anong klaseng herbal na medisina ang iyong ● Five-Leaved Chaste Tree (Lagundi)
madalas na ginagamit kapag mayroong nagkaka ● Onion (Bawang)
sakit?) ● Guava (Bayabas)
● Mint/Peppermint (Yerba Buena)
● None (Wala)
● Others (please specify): ___________ (Iba pa, pakitukoy)
General Instructions: Put a checkmark if the patient had the immunizations listed below.
(Panuto: Lagyan ng check kung isa sa miyembro ng pamilya ay nabakunahan na)
HEALTH AND ILLNESS PATTERNS
HISTORY OF IMMUNIZATIONS
(Sino sa pamilya ang nakatanggap na ng mga sumusunod na bakuna?)
Name of Family Flu Tetanus Hepatitis A Hepatitis B Measles, Measles, Pneumoc Diphtheria Polio Whooping COVID-19 Others (Mga
Member Vaccine Vaccine Vaccine Vaccine Mumps, Mumps, occal Immunizati Immunizati Cough vaccine ibang di
Rubella Rubella Vaccine on on Immunizati nabanggit na
Vaccine Vaccine on bakuna):
(1st dose) (2nd dose)
Editha Sanchez ● ● ● ● ● ● ● ● ● ● ●
Omar Sanchez ● ● ● ● ● ● ● ● ● ● ●
Migs Sanchez ● ● ● ● ● ● ● ● ● ● ●
Tamara Sanchez ● ● ● ● ● ● ● ● ● ● ●
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COVID-19 ASSESSMENT
Have you or any member of your household ● Yes (Oo)

traveled out of the country or went to places with Enumerate the location and date of travel
confirmed cases of COVID-19 in the past 14 days?
Location (Lugar) Date (Petsa)
(Nakarating ka ba o ang sinumang miyembro ng iyong
sambahayan ang naglakbay sa labas ng bansa o 1.
nagpunta sa mga lugar na may kumpirmadong mga
kaso ng COVID-19 sa nakaraang 14 araw?) 2.
3.
4.
● No (Hindi)
Have you or any member of your household had ● Yes (Oo)

an interaction with people who had travel history Where? (Saan?)___________
from places with confirmed COVID-19 cases for the ● No (Hindi)
past 14 days?
(Mayroon ka ba o sinumang miyembro ng iyong
sambahayan ang nakikipag-ugnayan sa mga taong
may kasaysayan ng paglalakbay mula sa mga lugar
na nakumpirma na mga kaso ng COVID-19 sa
nakaraang 14 araw?)
Have you or any member of your household had ● Yes (Oo)

an interaction with people who had been If yes, when (Exact date): __________
confirmed to have COVID-19? Location (Exact address if possible): ________
(Mayroon ka ba o sinumang miyembro ng iyong ● No (Hindi)
sambahayan ang nakipag-ugnay sa mga taong
nakumpirma na magkaroon ng COVID-19?) Note for the interviewer: If with exposure, ask the last known day/date of exposure.
Do you or any member of the household experience the following symptoms in the past 14 days? (Naranasan mo ba o ng sinumang miyembro ng
sambahayan ang mga sumusunod na sintomas sa nakaraang 14 araw?)
Name of Family Lagnat Ubo Sipon Hirap sa paghinga Pagtatae Pananakit ng Nawalan ng
Member lalamunan panlasa/pang-
amoy
Tamara Sanchez ● ● ● ● ● ● ●
● ● ● ● ● ● ●
● ● ● ● ● ● ●
● ● ● ● ● ● ●
● ● ● ● ● ● ●
● ● ● ● ● ● ●
● ● ● ● ● ● ●
Do you or any member of the household have an ● Yes (Oo)

interaction with a health worker who has direct
Name of Family Member Location (Lugar) Date (Petsa)
contact with a suspected/confirmed COVID-19
patient? (Mayroon ka ba o sinumang miyembro ng 1.
sambahayan ay may pakikipag-ugnay sa isang
manggagawa sa kalusugan na may direktang 2.
pakikipag-ugnay sa isang pinaghihinalaang /
nakumpirma na pasyente ng COVID-19?) ● No (Hindi)
Have you or any member of the household ● Yes (Oo)

attended a gathering (e.g., wedding, birthday party,
Name of Family Member Location (Lugar) Date (Petsa)
wake [of the deceased]) in the past 14 days?
(Nakarating ka ba o ang sinumang miyembro ng 1.
sambahayan ay dumalo sa isang pagtitipon ( e.g.,
kasal, kaarawan ng kaarawan, gisingin ang [ ng 2.
namatay ] ) sa nakaraang 14 araw?) ● No (Hindi)
Past and Present Health Concerns and Conditions

(Sino sa pamilya ang nagkaroon na ng mga sumusunod?)
Name of Family Acute Hypertension ALRTi & Urinary Tract Bronchitis Influenza Acute Asthma All Tuberculosi Acute Other/s (Please
Member Respiratory Pneumonia Infection Watery Forms s Febrile Specify):
(Pangalan ng Infection Diarrhea Illness Iba pa (mangyaring
kapamilya) tukuyin ito):
Editha ● ● ● ● ● ● ● ● ● ●
Omar ● ● ● ● ● ● ● ● ● ●
Migs ● ● ● ● ● ● ● ● ● ●
Tamara ● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ●
General Instructions: Put a check mark if the patient is diagnosed with a specific disease and provide the date beside the check mark. If not diagnosed, leave it
blank.
(Panuto: Lagyan ng check kung ang pasyente ay na-diagnosed ng partikular na sakit at ilagay ang petsa sa tabi nito. Kung hindi na-diagnosed, hayaang blanko.)
DIAGNOSED CONDITIONS
(Sino sa pamilya ang may kondisyon ng mga sumusunod, sa kasalukuyan?)
Name of Family Acute Hypertension ALRTi & Urinary Bronchitis Influenza Acute Asthma All Tuberculosis Acute Other/s (Please
Member respiratory Pneumonia Tract Watery Forms Febrile Specify):
(Pangalan ng infection Infection Diarrhea Illness Iba pa (mangyaring
Editha ● ● ● ● ● ● ● ● ● ●
Omar ● ● ● ● ● ● ● ● ● ●
Migs ● ● ● ● ● ● ● ● ● ●
Tamara ● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ●
MAINTENANCE MEDICATIONS
(Sino sa pamilya ang may iniinom na gamot para sa mga sumusunod?)
Name of Family Acute Hypertension ALRTi & Urinary Bronchitis Influenza Acute Watery Asthma All Tuberculosis Acute Other/s (Please
Member Respiratory Pneumonia Tract Diarrhea Forms Febrile Specify):
(Pangalan ng Infection Infection Illness Iba pa (mangyaring
● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ●
HOSPITALIZATIONS
When was your last hospitalization?

(Kailan ka huling na-ospital?)
FATHER MOTHER CHILD 1 CHILD 2 OTHER/S
● Last week ● Last week ● Last week ● Last week ● Last week
(Nakaraang (Nakaraang (Nakaraang (Nakaraang (Nakaraang
linggo) linggo) linggo) linggo) linggo)
● Last month ● Last month ● Last month ● Last month ● Last month
buwan) buwan) buwan) buwan) buwan)
● Last year ● Last year ● Last year ● Last year ● Last year
taon) taon) taon) taon) taon)
● Never (Hindi ● Never (Hindi ● Never (Hindi ● Never (Hindi ● Never (Hindi
kailanman) kailanman) kailanman) kailanman) kailanman)
● Others, please ● Others, please ● Others, please ● Others, please ● Others, please
specify: specify: specify: specify: specify:
__________ __________ __________ __________ __________
(Iba pa, (Iba pa, (Iba pa, (Iba pa, (Iba pa,
pakitukoy) pakitukoy) pakitukoy) pakitukoy) pakitukoy)
FATHER MOTHER CHILD 1 CHILD 2 OTHER/S
If applicable, why were you hospitalized that ● Dengue ● Dengue ● Dengue ● Dengue ● Dengue
time? (Kung oo, bakit ka na-ospital noong araw na

● Pneumonia ● Pneumonia ● Pneumonia ● Pneumonia ● Pneumonia
iyon?)
(Pulmonya) (Pulmonya) (Pulmonya) (Pulmonya) (Pulmonya)
● Injury (Pinsala) ● Injury (Pinsala) ● Injury (Pinsala) ● Injury (Pinsala) ● Injury (Pinsala)
● Others, please ● Others, please ● Others, please ● Others, please ● Others, please
specify: specify: specify: specify: specify:
__________ __________ __________ __________ __________
(Iba pa, (Iba pa, (Iba pa, (Iba pa, (Iba pa,
pakitukoy) pakitukoy) pakitukoy) pakitukoy) pakitukoy)
PEDIATRIC HEALTH QUESTIONNAIRE (FOR CHILDREN 5 YEARS AND BELOW)
QUESTIONS VITAL DATA OF VITAL DATA OF VITAL DATA OF OTHER/S (PLEASE OTHER/S (PLEASE
(MGA TANONG) CHILD 1 CHILD 2 CHILD 3 SPECIFY) SPECIFY)
(Mahalagang Datos ng (Mahalagang Datos ng (Mahalagang Datos ng (Iba pa, pakitukoy) (Iba pa, pakitukoy)
bata 1) bata 2) bata 3)
a. Child’s Birth Date: August 11, 2019

(Kapanganakan ng
Bata)
b. Gender: Female
(Kasarian)
c. Birthplace/ Hospital: Marikina City

(Lugar kung saan
pinanganak)
d. City: Marikina
(Lungsod)
QUESTIONS PREGNANCY DATA PREGNANCY DATA PREGNANCY DATA OTHER/S (PLEASE OTHER/S (PLEASE
(MGA TANONG) OF CHILD 1 OF CHILD 2 OF CHILD 3 SPECIFY) SPECIFY)
a. Duration of 38 weeks
Pregnancy:
(Tagal ng pagbubuntis)
b. Were there any ● Yes (Oo) ● Yes (Oo) ● Yes (Oo) ● Yes (Oo)
complications present ● If yes, ● If yes, when? ● If yes, when? ● If yes, when?
during pregnancy?: when? (Kung oo, (Kung oo, (Kung oo,
(Meron bang (Kung oo, kailan?)____ kailan?)____ kailan?)_____
komplikasyon habang kailan?)____ ● No (Hindi)
nagbubuntis?) ● No (Hindi) ● No (Hindi)
● No (Hindi)
If so, what month of

pregnancy?:
(Kung oo, anong
buwan?)
QUESTIONS DELIVERY DATA OF DELIVERY DATA OF DELIVERY DATA OF OTHER/S (PLEASE OTHER/S (PLEASE
(MGA TANONG) CHILD 1 CHILD 2 CHILD 3 SPECIFY) SPECIFY)
a. Birth Weight: 2.9 kilos

(Timbang ng kapanganakan)
Note: If the client doesn’t

remember the exact weight,
classify if overweight or
underweight.
(Tandaan: Kung hindi maalala

ng pasyente ang saktong
timbang, suriin kung sobra sa
timbang o kulang sa timbang)
b. Birth Length:
(Haba ng
kapanganakan)
c. Were there any

difficulties that the Yes, 24 hours of labor
mother encountered
during delivery?:
(Meron bang
paghihirap na
naranasan ang ina
habang
nanganganak?)
d. At 4 weeks, were None

there any of the
following?:
(Sa 4 na linggo,
mayroon bang alinman
sa sumusunod?:
● Breathing
problems
(Hirap sa
paghinga)
● Fever
(Lagnat)
● Convulsions
(Kombulsyon)
e. Was there yellowish None

skin color present
requiring treatment?:
(Mayroon bang
madilaw na balat na
nakikita na
kinakailangan ng
gamot?)
QUESTIONS BREASTFEEDING BREASTFEEDING BREASTFEEDING OTHER/S OTHER/S

(MGA TANONG) DATA OF CHILD 1 DATA OF CHILD 2 DATA OF CHILD 3 (PLEASE SPECIFY) (PLEASE SPECIFY)
a. When did you start Since birth

breastfeeding?
(Kailan ka nagsimulang
magpasuso?)
b. When did you stop At her one year old

breastfeeding?
(Kailan ka tumigil sa
pagpapasuso?)
c. How many times does 2every 2 hours

the baby go for
breastfeeding?:
(Ilang beses
nagpapasuso ang
sanggol?)
d. How many times does every 2 hours

the baby go for
breastfeeding?:
(Ilang beses
nagpapasuso ang
sanggol?)
e. Did you have any None

complications
encountered during
your breastfeeding
period?: (Mayroon ka
bang anumang
komplikasyon na
naranasan sa panahon
ng iyong
pagpapasuso?)
If so, please specify:

_________
FAMILY PLANNING
Do you use a family planning method? ● Yes (Oo)

(Gumagamit ka ba ng paraan ng pagpaplano ng If yes, specify: (Kung oo, anu-ano ang mga ito)
pamilya?)
● Natural ● Calendar method
Paraan ng
kalendaryo
● Artificial ● Condoms
Artipisyal ● IUD
● Pills
● Permanent ● Tubal Ligation

Permanente ● Vasectomy
● No (Hindi)
HEALTH LIFESTYLE AND ACTIVITIES
Name of Family Exercise If yes, how often? If yes, what kind of Smoker If yes, how many Drinker If yes, how often?
Member (Ehersisyo) (Kung oo, gaano exercise (Naninigarilyo) stick/s or pack/s (Mang-iinom) (What type of alcohol?
(Pangalan ng kadalas?) (Kung oo, anong uri consumed a day? Kung oo, gaano
Miyembro ng ng ehersisyo) (Kung oo, ilang piraso kadalas?
Pamilya) o kaha ang Anong klase ng alak?)
nakukunsumo sa
isang araw?)
Editha ● Twice a week Jogging ● ● Trice a week
Omar ● Everyday Cycling ● 7 sticks a day ● Trice a week
Migs ● ● ●
Tamara ● ● ●
● ● ●
● ● ●
● ● ●
● ● ●
● ● ●
● ● ●
● ● ●
● ● ●
● ● ●
ESTADO NG NUTRISYON
NAME OF FAMILY MEMBER

UNDERWEIGHT NORMAL OVERWEIGHT
(PANGALAN NG MIYEMBRO NG
(KULANG SA TIMBANG) (NORMAL NA TIMBANG) (SOBRA SA TIMBANG)
PAMILYA)
YES (Oo) NO (Hindi) YES (Oo) NO (Hindi) YES (Oo) NO (Hindi)
Edithaa ● ● ● ● ● ●
OmarOmar ● ● ● ● ● ●
MigsMigs ● ● ● ● ● ●
TamaraTamara ● ● ● ● ● ●
● ● ● ● ● ●
● ● ● ● ● ●
● ● ● ● ● ●
● ● ● ● ● ●
● ● ● ● ● ●
● ● ● ● ● ●
Food Sanitation
(Kalinisan ng pagkain)
What kind of food preparation do you do when ● Handwashing (Paghuhugas ng kamay)

cooking? ● Wearing protective garments (Hairnet, apron, gloves, etc.)
(Anong klaseng paghahanda ang ginagawa mo sa (Pagsusuot ng mga hairnet, apron, gloves, etc.)
pagluluto?)
Where do you store foods before cooking? ● Refrigerator

(Saan mo iniimbak ang mga pagkain bago magluto?) ● Cabinet (Aparador, Kabinet)
● Floor (Sahig)
● Table (Lamesa)
● None (Wala)
Where do you store your food after cooking? ● Refrigerator

(Saan mo iniimbak ang iyong pagkain pagkatapos ● Cabinet (Aparador, Kabinet)
magluto?) ● Floor (Sahig)
● Table (Lamesa)
● None (Wala)
● Others, please specify: __Tupperware__ (Iba pa, pakitukoy)
What are the method used in cooking foods? ● Fried (Prinito)

(Ano ano ang mga paraan na ginagamit sa pagluluto ● Boiled (Nilaga, Pinakuluan)
ng pagkain?) ● Steamed (Na-steam)
● Grilled (Inihaw)
Food Intake
What kinds of unhealthy foods do you eat?

(Anong mga uri ng hindi malusog na pagkain ang Name of Family Eating junk Eating processed Drinking soft Others, please
kinakain mo?) member foods (Kumakain foods (e.g. drinks more than specify: (Iba
Pangalan ng ng junk foods) hotdog) (Kumakain once a week pa, pakitukoy)
miyembro ng ng mga
(Umiinom ng soft
pamilya prinosesong
pagkain - hal. drinks na higit sa
hotdog) isang beses sa
isang linggo)
Editha ● ● ●
Omar ● ● ●
Migs ● ● ●
Tamara ● ● ●
● ● ●
How many meals does the family eat in a day?

(Ilang beses sa isang araw kumakain ang pamilya sa Name of Family 1 - 2 meals daily 3 - 5 meals daily (Tatlo 6 or more daily
loob ng isang araw?) Member (Isa hanggang hanggang limang beses) (Anim na beses o
(Pangalan ng dalawang beses) higit pa)
miyembro ng
pamilya)
Editha ● ● ●
Omar ● ● ●
Migs ● ● ●
Tamara ● ● ●
● ● ●
What specific foods does your family usually

prepare when eating inside the house (Breakfast, Name of Family Breakfast Lunch Snacks Dinner Midnight
Lunch, Snacks, Dinner, Midnight Snacks)? Member (Umagahan): (Tanghalian): (Meryenda): (Hapunan): Snacks
(Pangalan ng (Pang gabing
miyembro ng meryenda):
pamilya)
(Anong uri ng mga pagkain ang madalas na Editha Kanin Kanin Kanin
inihahanda sa loob ng iyong tahanan (Umagahan,
tanghalian, meryenda, hapunan, pang-gabing Omar Kanin Kanin Kanin
meryenda)?
Migs Pandesal Kanin Biscuits Kanin
Tamara Gatas Kanin Biscuits Kanin
Do you use the following while preparing your ● Betsin (MSG) Ex. Aji-no-moto
food? ● Magic Sarap
● Knorr Cubes
(Gumagamit kaba ng mga sumusunod sa paghahanda ● Knorr Seasoning

ng pagkain?) ● Others, please specify: __________ (Iba pa, pakitukoy)
How many times per week do you eat:

(Ilang beses ka kumakain sa isang linggo?)
NAME OF FAMILY VEGETABLES FRUITS RED MEATS CHICKEN SEAFOODS

MEMBER (Gulay) (Prutas) (Karne) (Manok) (Pagkaing dagat)
(Pangalan ng
miyembro ng pamilya)
Editha Sanchez ● 1 - 2 times per week ● 1 - 2 times per ● 1 - 2 times per ● 1 - 2 times per week ● 1 - 2 times per
(Isa o dalawa sa week (Isa o dalawa week (Isa o dalawa (Isa o dalawa sa week (Isa o dalawa
isang linggo) sa isang linggo) sa isang linggo) isang linggo) sa isang linggo)
● 3 - 5 times per week ● 3 - 5 times per ● 3 - 5 times per ● 3 - 5 times per week ● 3 - 5 times per
(Tatlo hanggang lima week (Tatlo week (Tatlo (Tatlo hanggang lima week (Tatlo
sa isang linggo) hanggang lima sa hanggang lima sa sa isang linggo) hanggang lima sa
● 6 or more per week isang linggo) isang linggo) ● 6 or more per week isang linggo)
(Anim o higit pa sa ● 6 or more per week ● 6 or more per week (Anim o higit pa sa ● 6 or more per week
isang linggo) (Anim o higit pa sa (Anim o higit pa sa isang linggo) (Anim o higit pa sa
isang linggo) isang linggo) isang linggo)
Omar Sanchez ● 1 - 2 times per week ● 1 - 2 times per ● 1 - 2 times per ● 1 - 2 times per week ● 1 - 2 times per
Migs Sachez ● 1 - 2 times per week ● 1 - 2 times per ● 1 - 2 times per ● 1 - 2 times per week ● 1 - 2 times per
Tamara Sanchez ● 1 - 2 times per week ● 1 - 2 times per ● 1 - 2 times per ● 1 - 2 times per week ● 1 - 2 times per
● 1 - 2 times per ● 1 - 2 times per ● 1 - 2 times per ● 1 - 2 times per ● 1 - 2 times per
week (Isa o dalawa week (Isa o dalawa week (Isa o dalawa week (Isa o dalawa week (Isa o dalawa
sa isang linggo) sa isang linggo) sa isang linggo) sa isang linggo) sa isang linggo)
week (Tatlo week (Tatlo week (Tatlo week (Tatlo week (Tatlo
hanggang lima sa hanggang lima sa hanggang lima sa hanggang lima sa hanggang lima sa
isang linggo) isang linggo) isang linggo) isang linggo) isang linggo)
● 6 or more per week ● 6 or more per ● 6 or more per ● 6 or more per week ● 6 or more per
(Anim o higit pa sa week (Anim o higit week (Anim o higit (Anim o higit pa sa week (Anim o higit
isang linggo) pa sa isang linggo) pa sa isang linggo) isang linggo) pa sa isang linggo)
Are there any specific foods that the member of the

family is allergic with? Please specify. Name of Family Member Allergies
(Pangalan ng miyembro ng pamilya) (Alerdyi)
(Mayroon bang uri ng pagkain kung saan ay may
alerdyi ang isa sa miyembro ng pamilya? Kung 1. Editha Sanchez Alamang
mayroon, paki tukoy.)
2. Tamaa Sanchez Alamag
3.
4.
5.
6.
Drinking Water Sanitation
Do you store water in your house, if so how? ● Covered (Baldeng may takip)
● Uncovered (Baldeng walang takip)
(Nag-iimbak ba kayo ng tubig sa inyong tahanan? Kung ● No need to store water (Hindi nag-iimbak ng tubig)
oo, sa paanong paraan?)
Note: Recite the choices
What type of method does the family use in ● Boiling (Pagpapakulo ng tubig)
sanitizing their drinking water? ● Filtration (Pagsasala ng tubig)
● Buying commercially prepared water (Bumibili ng tubig sa mga water refilling stations o
sa grocery)
(Ano'ng pamamaraan ang ginagamit ng inyong pamilya
● No method of sanitizing (Walang paraan ng paglilinis)
upang siguruhin ang kalinisan ng inyong tubig na inumin?)
HEALTH RESOURCES
A. MANPOWER RESOURCES
Health Information Resources, Health Information Seeking Behavior and Consumption

(Pinagkukunan, Paghahanap, at Paggamit ng Impormasyong Pangkalusugan)
What is your main source of health information? ● Family members (Mga miyembro ng pamilya)
(Ano ang iyong unang pinagkukunan ng impormasyong pangkalusugan?) ● Media
● Doctors, nurses and other healthcare professionals (Mga doktor, nars at iba
pang mga propesyonal sa healthcare)
● Herb doctor (Albularyo)
● Barangay Health Workers (Mga Nagtatrabaho sa Barangay Health)
● LGU
What do you usually do if you want to know more about some ● Consults with your friends, relatives or partners
health information? (Select all that apply) (Kumukonsulta sa mga kaibigan, kamag-anak o kasosyo)
(Ano ang madalas mong ginagawa kapag gusto mong may malaman na ● Searches in the internet
impormasyong pangkalusugan?) (Naghahanap sa internet)
● Reads pamphlets
(Nagbabasa ng mga pamphlet)
● Attends meetings, classes, lectures, presentations or seminars
(Umattend sa mga meeting, klase, lecture, presentasyon o seminar)
● Reads newspaper articles
(Nagbabasa ng mga diyaryo)
● Consults with a healthcare professional
(Kumukonsulta sa isang propesyonal sa healthcare)
● Watches television programs or listens to radio

(Nanonood ng mga programa sa telebisyon o nakikinig sa radyo)
● Reads textbooks
(Nagbabasa ng mga libro)
● Consults in churches or religious figures
(Kumukonsulta sa mga simbahan o mga relihiyosong pigura)
How do you verify if the source/s you have used is/are credible? ● Reliable source (e.g. credentials of website/s and/or author/s)
(Check all that applies) (Maaasahang mapagkukunan - hal. Mga datos mula sa gobyerno o mga isinulat
(Paano mo sinisugarado na ang mga pinagkunan ng impormasyon na ng mga propesyonal na lehitimo)
ginamit ay mapagkakatiwalaan?) ● Double check with health professionals or check a website/blog by health
(Suriin ang lahat ng naaangkop) professionals
(Ipakonsulta sa mga doktor o nars o kaya mula sa mga website na naislulat ng
mga dokotor o nars)
● Ask from peers who are more experienced (friends from the healthcare
industry)
(Magtatanong sa mga kakilala na may kaparehas na karanasan o may alam sa
kalusugan)
● Cross-reference with other sources
(Paggamit ng mahigit sa isang pinagkukunan ng impormasyon)

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G22A-Interview-Tool-with-answer (2) (Repaired)

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Pamantasan ng Lungsod ng Marikina

2 Brazil St., Greenheights Subd., Concepcion Uno, Marikina City

1. Editha Sanchez M 30 F Antique M Catholic College House Filipino Filipino 75 kg 5’3

2. Omar Sanchez F 42 M Paco M Catholic Highscho Kitchen Filipino Filipino 86 kg 5’8

3. Migs Sanchez C 7 M Quezon City S Catholic Grade 2 - Filipino Filipino 27 kg 121 cm

4. Tamara Sanchez C 3 F Marikina City S Catholic - - Filipino Filipino 15 kg

Primary Source of Income Omar Sanchez (Father)

Other Sources of Income None

Combined Family Income per Month 14,000

Informant Name and Contact Number 09103560609

Interviewed By Franz Isaiah Fabillar

Sex (Kasarian) M) Male (lalaki) (F) Female (babae)

SOCIO-ECONOMIC AND CULTURAL VARIABLES

Place of Residence (Lugar Kung Saan Nakatira)

What kind of neighborhood is your home ● Village

Does your family experience any conflict ● Always (Palagi)

What is the property that you are currently ● Owned (Pagmamay-ari)

Note: Provide the choices

How many rooms do you have in your ● 1 - 2 (Isa hanggang dalawa)

How many people share rooms? ● 2 people (Dalawang tao)

● 3 people (Tatlong tao)

How many windows are there in your

How often do you clean your house? ● Daily (Araw-araw)

Do you maintain and check your drainage ● Daily (Araw-araw)

Do you have a toilet with a flush? ● With (Meron)

Is there a presence of pests (e.g., ● With (Meron)

(Mayroon bang presensya ng peste, ipis, at

If yes, what type of pests do you usually see ● Cockroaches (Ipis)

What are the breeding sites that are found in

Holes (Mga butas o ● ●

Below the stairs ● ●

Do you have any domestic animals in your ● Yes (Oo)

Do you have domestic animals at home?

Others, please specify: ● ●

Are they vaccinated?

Others, please specify: ● ●

Availability of Social and Health Facilities

What kind of healthcare facility is near your ● Clinics (Mga klinika)

How far is it from your house? ● Walking distance (Kayang lakarin)

In case of emergencies, where do you ● Clinics (Mga klinika)

NOTE: (Interviewer) Recite the choices

Does your local barangay office have a clinic ● Yes (Oo)

Availability of Communication and Transportation Facilities

Do you have an internet connection at ● With (Meron)

(Mayroon ba kayong internet connection sa

How often do you lose network signals in ● Daily (Araw-araw)

What is your usual mode of transportation? ● Train (MRT, LRT)

Do you belong in any organization that is related to

Have you participated in seminars or projects related to

Relationship to Larger Communities

Do you participate in your neighborhood’s associations ● Yes (Oo)

Nakikilahok ka ba sa ososasyon ng inyong lugar katulad ng

Are you involved in any of the services of your ● Yes (Oo)

Ikaw ba ay napapabilang sa mga serbisyo ng iyong

Are you willing to partake in outreach activities your ● Yes (Oo)

Ikaw ba ay pumapayag na makilahok sa aktibidad na

Are you willing to take part or volunteer in activities ● Yes (Oo)

Ikaw ba ay pumapayag na makilahok o mag boluntaryo sa

Income and Expenses

What is the estimated range of your monthly

What is the estimated range of your monthly

Who is in charge of managing the money in the ● Mother (Nanay)

Do you have health insurance? ● With (Meron)

If yes, what type of health insurance did you invest ● PhilHealth