I.

INITIAL DATA BASE

A. What is the type of family structure?

_✓_ Nuclear Extended Others (Please Specify):

B. Head of the family: Mother

C. Members of the Household:

MEMBERS OF THE Position in EDUCATIONAL

AGE SEX CIVIL STATUS
HOUSEHOLD the Family ATTAINMENT

J.L Mother 52 F Married Undergraduate

I.L Father 56 M Married Undergr

aduate

K.L Sister 29 F Single Undergr

aduate

F.L Sister 27 F Single College

Graduate

N. L Sister 23 F Single College

D. L Sister 20 F Single College

B.L Son 19 M Single Senior High

School

II. SOCIO-ECONOMIC AND CULTURAL CHARACTERISTICS

A. Income

Income and Expenses

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

J.L Businesswoman Caloocan - ✓

City
I.L Catery Malabon -
City
-
B. Does the working family meet the basic necessities? _✓_Yes No

C. Who makes decisions regarding money matters? _Mother

D. Religious affiliation? _None

E. What role does the family play in the community? _Tumutulong sa mga Mahihirap

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):_Compound

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

I.L Hypertension Removed MEDICATION

K.L Hypertension Removed Medication

B. Immunization

NAME AGE SEX BCG DPT OPV HEPA B MEASLES

J.L 52 F ✓ ✓ ✓ ✓ ✓

I.L 56 M ✓ ✓ ✓ ✓ ✓
K.L 29 F ✓ ✓ ✓ ✓ ✓
F.L 27 F ✓ ✓ ✓ ✓ ✓
 N.L 23 F ✓ ✓ ✓ ✓ ✓
D.L 20 F ✓ ✓ ✓ ✓ ✓
B.L 19 M ✓ ✓ ✓ ✓ ✓

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 J.L 52 Read and write

2 I.L 56 Read and write
3 K.L 29 Read and write
4 F.L 27 Read and write
5 N.L 23 Read and write
6 D.L 20 Read and write
7 B.L 19 Read and write
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
 - Catery
- Carpenter
- Sales Lady
- Eyelash and Nail extension
- 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 J.L Self-Employed
2 I.L Catery
3 K.L Sales lady
4 F.L Carpenter
5 N.L Government employee
6
7

C.2.4 Occupation Status

- Employed Contractual
- Employed Regular
- Self Employed
- Unemployed

Family member workers

Occupational status
initials

1 J.L Self-Employed
2 I.L Employed Regular
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):