I.

INITIAL DATA BASE

A. What is the type of family structure?

__ Nuclear __Extended Others (Please Specify):

B. Head of the family: _____________________

C. Members of the Household:

MEMBERS OF THE Position in EDUCATIONAL

AGE SEX CIVIL STATUS
HOUSEHOLD the Family ATTAINMENT

II. SOCIO-ECONOMIC AND CULTURAL CHARACTERISTICS

A. Income

Income and Expenses

MEMBERS OF THE
WHO MAKES
HOUSEHOLD PLACE OF
OCCUPATION INCOME DECISION ABOUT
WORK
MONEY

B. Does the working family meet the basic necessities? __Yes __No
C. Who makes decisions regarding money matters? __Yes __No

D. Religious affiliation? _____________

E. What role does the family play in the community? __________________

F. During Covid-19 Pandemic

MEMBERS OF THE LAYOFF ACTION

HOUSEHOLD

III. ENVIRONMENTAL FACTORS

A. Home:

Ownership:

__Owned __Rented Others (Please Specify):____________

Number of Rooms:

__One __ Two __Three Others:____

Construction Materials Used:

__Strong __Mixed __Light __Makeshift

Other (Please Specify): __________

Sanitary Condition:

__Good __Fair __Poor

Water Source:

__Private __Public

Water Storage

__Jar __Can __Drum & Pail etc.

Excrete Disposal: __Sewage __Septic Tank __Water-sealed

__Public Comfort Room Others (Please Specify): ___________
 Garbage Disposal:

__Dumped at Street Corner __Buried

__Picked up by Garbage Collector __Burned then buried

Neighborhood:

__Congested __Slum Others (Please specify):___________

Source of Health Care:

__Health Center __Private Clinic

__Hospital Others (Please Specify):_____

IV. HEALTH MEDICAL HISTORY

A. Presence of Illness

__Diagnosed __Undiagnosed __None

NAME PAST ILLNESS ILLNESS STATE HEALTH ACTION

B. Immunization

NAME AGE SEX BCG DPT OPV HEPA B MEASLES

 C. Communicable Diseases (e.g TB, leprosy etc.)

Communicable Disease (f any) Under treatment Not Under treatment

If under treatment, where is it being treated? ___________________________

V. Transport and Communication Facilities

A. Transportation

__Bus __City Bus Other (Please Specify):

__Tricycle __Jeepney ______________

__Taxi __Private

B. Communication

__Cellular Phone __Radio

__Telephone Others (Please specify):

__Television ___________________
B. Socio-Economic and Cultural Variables

C.1 Cultural Variables

C.1.3 Place of Origin

⃝ Luzon
⃝ Visayas
⃝ Mindanao
⃝ Others (Pls specify): ____________________

C.1.4 Length of Residency

⃝ Less than 6 months

⃝ 6 months - 1 year
⃝ 1 yr. - 5 years
⃝ 6 yrs. - 10 years
⃝ 10 yrs. & above

C.1.5 Language / Dialect

⃝ Tagalog
⃝ Bisaya
⃝ Kapampangan
⃝ Ilocano
⃝ Mixed Pls specify_______________________
⃝ Others (Pls specify): ____________________

C.2 Economic indicators

C.2.2 Literacy Rate (7y/o & above)

- Can read and write

- Cannot read and write

Family members initials Age Can…

1
2
3
4
5
6
7
8
9
10
11
All the members should be in list. Pero ung 6 y/o pababa, i-blanko nlng, initials at age lng
ilagay.
C.2.4 Occupation

- Health Care Worker

- White Collared Jobs
- Blue Collared Jobs
- OFW
- Government Employee
- Self-employed
- Unemployed

*Blue-collar workers are those who do manual labor and are paid on an hourly or piecework
basis. White-collar workers are known as suit-and-tie workers who work in service industries
and are paid salaries.

Family member workers

Occupation
initials

1
2
3
4
5
6
7

C.2.4 Occupation Status

- Employed Contractual
- Employed Regular
- Self Employed
- Unemployed

Family member workers

Occupational status
initials

1
2
3
4
5
6
7

C.3 Environmental

C.3.8 Plants

⃝ Herbal
⃝ Vegetables
⃝ None
⃝ Others (Pls specify): ___________________
C.3.9 Domestic / Pet Ownership

⃝ Dog
⃝ Cat
⃝ Others
⃝ None

C.3.10 Commercial Animals

⃝ Pig
⃝ Chicken
⃝ Cow
⃝ Goat
⃝ None
⃝ Others (Pls specify): ____________________

D. Health / Illness profile

D.2 Food Storage

⃝ Refrigerated
⃝ Cabinet
⃝ Basket
⃝ Table
⃝ Others (Pls specify): ____________________

D.3 Infant Feeding Practices

Does your family have an infant in need of breastfeeding or bottle feeding?
⃝ Yes
⃝ No
If yes:

⃝ Breastfeeding
⃝ Bottle feeding
⃝ evaporated
⃝ condensed
⃝ powdered
⃝ Infant Formula
⃝ water & dissolved sugar

D.5 Health Seeking Behaviors

⃝ Doctor
⃝ Nurse
⃝ Midwife
⃝ Brgy. Health Worker
 ⃝ Elders etc.
⃝ Others (Pls specify): ____________________

D.7 Family Planning

⃝ Natural Method
⃝ Pills
⃝ Condom
⃝ Non-Acceptor
⃝ Others (Pls specify): ____________________