Beruflich Dokumente
Kultur Dokumente
Respondent: _____________________________________________
Age: _____________
Sex: _____________
Relation to Head: ________________________ (If not the head of the
family)
I.
Family Data
A. Head of the Family _____________________________
Age: ___________
B. Name of Spouse _______________________________
Age: ___________
C. Address ________________________________________
D. Educational Attainment _________________________
Husband: _________________________________
Wife: _____________________________________
E. Length of Residency _____________________________
F. Family Structure
) Nuclear
(
( ) Extended
) Single-Parent
(
G. Religion ________________________________________
H. Number of Children______________________________
I. Members of the Household
Name
Age
Sex
Education
Occupation
( ) Frequently
( ) Never
( ) Frequently
( ) Never
( ) (Frequently
( ) (Never
( ) (Frequently
( ) (Never
( ) (Frequently
( ) (Never
( ) Frequently
( ) Seldom
( ) Never
C. Does it accept member as they are?
( ) Most of the time
( ) Seldom
( ) Frequently
( ) Never
( ) (Frequently
( ) (Never
( ) (Frequently
( ) (Never
( ) (Frequently
( ) (Never
( ) (Frequently
( ) (Never
( ) (Frequently
( ) (Never
Socioeconomic Data
A. Source of Income
Occupation: _______________________________
Husband: __________________________________
Wife: _______________________________________
Employed ( )
Unemployed ( )
( ) Self Employed
Monthly Income:
( ) Below P2,000
( ) P5,000 - P8,000
( ) P2,000 - P5,000
( ) more than P8,000
( ) P50 P75
Clothing:
2.
Number of times buying
( ) Once a year
( ) Twice a year
( ) Thrice a year
( ) Monthly
Housing
3.
( ) Water
( ) Telephone
( ) Electricity
( ) Internet Access
Schooling
( ) Public
III.
( ) Private
Type:
Adequacy of Living Space
( ) Adequate
( ) Inadequate
Ventilation:
( ) Good
( ) Poor
Lighting:
( ) Candles
( ) Fluorescent
( ) Lamp
( )Others, pls. specify_______________
Sleeping Arrangement
( ) Bedroom
( ) Outside the house
( ) Sala
( ) Others, pls. specify_______________
( ) Covered
( ) Others, pls. specify_______________
Containers Used:
( ) Plastics
( ) Bottles
( ) Clay Jars
( ) Others, pls. specify_______________
D. Toilet Facilities
Sanitary:
( ) Flush
( ) Shared
( ) Public
( ) Pit Privy
( ) Owned
( ) Others, pls. specify_______________
Unsanitary
( ) Balot System
E. Garbage Disposal
( ) Collection
( ) Burying
( ) Others, pls. specify_______________
( ) Burning
( ) Open Dumping
F. Food Storage
( ) Refrigerated
( ) Uncovered
( ) Covered
( ) Others, pls. specify_______________
Containers Used:
( ) Plastics
( ) Metal Pots
( ) Clay Pots
( ) Others, pls. specify_______________
G. Presence of Animals
( ) Dogs
( ) Cats
( ) Cows
( ) Pigs
( ) Chickens
( ) Others, pls. specify_______________
( ) Flower Pots
( ) Discarded Tires
( ) Canals
( ) Others, pls. specify______________
( ) None
Types:
( ) Broken Stairs
( ) Plastics
( ) Improperly Kept Medicines
( ) Pointed/ Sharp
Materials
( ) Banana Peelings
( ) Chemicals
( ) Uncemented
( )Private
( ) Others, pls. specify_________________
Nutrition
A. Food Preferences
( )(Fish
( )(Fruits/ Vegetables
( ) Meat
( ) Mixed
B. Common Fare
( )(Rice and Egg
( )(Rice and Noodles
3. Vitamin A Deficiency
( ) Night Blindness ( ) Pilak sa Mata
( ) Others, pls. specify___________________
4. Obesity
BMI: ___________________________
Waist Circumference: __________
WHR: __________________________
VI.
( ) (No
B. Reason:
(
(
(
(
) Illness
( ) (Prenatal
) Family Planning
( ) (Postnatal
) Dental
( ) (Nutrition
) Others, pls. specify___________
______
( ) (Colds
( ) (Others, pls. specify___________
( ) Consultation
( ) Hospital
(
( ) Others,
(
pls. specify______________
( ) (Health Station
E. Other Diseases
( ) (Tuberculosis
) L( ) (Leprosy
( ) (Skin Diseases
( ) (Hepatitis
( ) (Others, pls. specify_______________
F. Do you submit your children (0-12 months) for
immunization?
Name of
Child
Birthday
BCG Hep
B
G.
Do you practice Family Planning Methods?
( ) Yes
( ) No
If No, Why? __________________________________________________
H. Method of Infant Feeding?
( ) (Breast
( ) (Bottle
( ) (Mixed
( ) (Others, pls. specify_______________
H. Subjects you want to learn in health education?
( ) Drug Abuse
( ) Nutrition
( ) Family Planning
( ) First Aid Measures
( ) Others, pls. specify_______________
( ) (Environmental
Sanitation
( ) (Herbal Plants