Republic of the Philippines

Province of Pampanga
Municipality of Porac

Barangay:________________________________________
Name of BPW:____________________________________

TEEN PREGNANCY PROFILE

10 to 24 years old

Name: _________________________________________________________ Age: ____________

Complete Address: ________________________________________________________________
Birthday: _______________________________ Religion:__________________________________

Civil Status: Married Live-in Single Parent

Educational Attainment: __________________________ ISY OSY

If Out-of-School youth (OSY), Reason for drop-out:_____________________________________
Occupation:__________________________________ Monthly Income:____________________

Name of Husband/Partner:__________________________________________ Age: __________

Complete Address:________________________________________________________________
Educational Attainment: __________________________ ISY OSY
If Out-of-School youth (OSY), Reason for drop-out:_____________________________________
Occupation: ________________________________ Monthly Income: Php___________________
No. of Children:_______
Kasarian
Pangalan ng Anak Birthday Edad
Babae Lalaki

Ano ang ginagamit na Family Planning Method? _______________________________________

Kung wala, ano ang gustong gamitin? ________________________________________________
Kung walang gustong gamitin na family planning methods, ano ang dahilan?
_________________________________________________________________________________
Ano ang mga pangunahing pangangailangan mo bilang isang kabataan/batang ina sa panahon
ng pandemya?____________________________________________________________________
Sa paanong paraan makakatulong ang gobyerno sa mga katulad ninyong mga kabataan sa
panahon ng pandemya? ____________________________________________________________
_________________________________________________________________________________
Bilang isang batang ina, ano ang mga gusto mong gawin para sa ikagaganda ng iyong
kinabukasan at ng iyong anak?_______________________________________________________

Pangalan at Lagda