Republic of the Philippines

Department of Health
REGIONAL OFFICE MIMAROPA
QMMC Compound, Project 4, Quezon City

LIFESTYLE RELATED DISEASES (LRDs) SURVEY FORM

NAME:
Sex:

O Male
O Female
O Single
O Married
O Widow/er
O Co-Habilitation

Civil Status:

O Separated

Permanent Address:
Birthdate:
Blood Type:

( ) A+
O-

( ) A-

( ) B+

( ) B-

( ) AB+

( ) AB-

( ) O+

Place of Birth:
Philhealth ID #:
NHTS ID #:
CCT/4P member:

O Yes

O No

Mobile #:

Landline #:

Email Address:
Religion:
Nationality
IPs

O No

O Yes (pls. specify_____________________)

Present Illness:
O Diabetes Mellitus
O Cancer
O Chronic Respiratory Diseases (pls. specify)
O Stroke
O Hypertension
O Renal Disease
O Others: (pls. specify)
Current Smoker:

O Yes

O No

Quit Smoking:

O Yes

O No (if yes: When?:____________________)

Drinking
Alcohol/Beverage:

O Yes
O No
If YES, Type:____________, Amount:____________
Frequency:_____________

Age Started
Smoking:
Contact Person:
Address:

()

Contact Number: