Beruflich Dokumente
Kultur Dokumente
Name Relation to head Sex Age Marital Educational Occupation Place Health
Status Attainment Type of work Remarks
HOME AND ENVIRONMENT Date Assessed: ________
1. Home
a. Ownership: ( ) Owned ( ) Rental ( ) real –Free
b. Construction Materials used: ( ) Light ( ) Mixed
c. Number of rooms used in sleeping: __________
d. Lighting Facilities: ( ) Electricity ( ) Kerosene ( ) Others Specify: ___________
e. General Sanitary Condition: ____________________________
2. Water Supply
a. Drinking Water
Source: ( ) Private ( ) Public
Distance from the house : _____________
Storage: ( ) none (direct from faucet or pipe)
( ) Jar or can with faucet
( ) Jar or can without faucet
( ) Others (specify) ______________
3. Kitchen
a. Cooking Facilities: ( ) electric stove ( ) gas stove ( ) Firewood
b. Sanitary Condition: _______________
c. Drainage Facility: ( ) none ( ) Open Drainage
4. Water Disposal
a. Refuse Garbage
(1) Container: ( ) covered ( ) open ( ) none
(2) Method of Disposal:
( ) Hog Feeding ( ) Composing
( ) Open Dumping ( ) Incineration
( ) Open Burning ( ) Others Specify: _______________
( ) Basial in Pit
b. Toilet
(1) Type
( ) None ( ) Antipolo System
( ) Pail System ( ) Water – sealed Latrine
( ) Open pit privy ( ) Flush Type
( ) Closed pit privy ( ) Others Specify: ________________
( ) Bored – hole latrine
( ) Overhung latrine
(2) Distance from the house: _______________________________________
(3) Sanitary Condition: ____________________________________________
5. Domestic Animals
Kind Number Where Kept
________________ __________________ ____________________
________________ __________________ ____________________
2) Demographic Data
________________________________________________________________
1) Income Expenses
4) Significant Others
___________________________________________________________
a. Anthropometric data
Mid-Upper arm circumference ______________
Height ______________
Weight ______________
c. Eating/Feeding habit/Practices
_____________________________________________________
_____________________________________________________
Date: _________________________________________
Time: _________________________________________
A. HEALTH TREATS
B. HEALTH DEFICITS
Problem: ____________________________________________________________
3. Preventive Potentials _ x 1
3
4. Salience _ x 1
2
TOTAL = _______________
Problem: ____________________________________________________________
3. Preventive Potentials _ x 1
3
4. Salience _ x 1
2
TOTAL = _______________
Problem: ____________________________________________________________
3. Preventive Potentials _ x 1
3
4. Salience _ x 1
2
TOTAL = _______________
1. ________________________________________________________________
2. ________________________________________________________________
3. ________________________________________________________________