A4 Print CDX
A4 Print CDX
City of Malolos
I. Demographic Variable
OCCUPATION L
BIRTHDATE E
Type Place of Work N
M G
P
L T
A
R
R A H
E I
G I
HIGHEST C
RELATION E T L f C O
A EDUCATIONAL L E
-SHIP TO
N A I S E A F
# NAME OF FAMILY MEMBER THE HEAD G COMPLETED (3 O
D L G T M T R
OF THE E YEARS OLD C O
FAMILY E I AND ABOVE)
A P E E
R M D Y S A F
O T L G S
T T
N U O O I
A I O
S Y R D
T O R
U E Y E
N I
S D N
G
I C
N E
1 Lorena R. Pangan 2 33 May 19 89 3 1 4 6
2 Bernardo C. Pangan Husband 1 34 Nov 08 80 3 1 8 1 6 1 1 1 6
3 Aidelle Isaac R. Pangan Son 1 7 Aug 14 15 1 1 2 6
4 King Nigel R. Pangan Son 1 3 Sept 24 19 1 1 3
LEGEND:
Gender: Marital Status: Religion: Education:
1- Male 1- Child 1- Roman Catholic 1- Pre- elem. 8- College Level
2- Female 2- Single 2- Muslim 2- Elem. Level 9- College Grad.
3- Married 3- Iglesia ni Cristo 3- Elem. Grad. 10- Post- Grad.
4- Married but Separated 4- Born Again Christian 4- High School Level 11- Over 7 years
5- Widow 5- Jehova’s Witness 5- High School Grad old w/o formal
6- Widower 6-Protestant (Methodist; 6- Vocational schooling
Evangelical; Baptist; Adventist) 7- Short Course 12- <5 yeas old
7-others: 13- SPED
TYPE OF WORK:
STATUS:
1 - Employed Place of Work:
1- Regular Full-time Location: Category: Place of Origin:
2- Regular Part- time 1- with in the community 1- In-House 1- Metro Manila
3- Contractual 6 months 2- with in the municipality/city 2- Field 2- Central Luzon
4- Contractual every week 3- outside the municipality/city 3- Office 3- Northern Luzon
5- Contractual everyday 4- OFW- outside the country 4- Southern Luzon
6- Self- Employed 5- Visayas Region
7- Seasonal 6- Mindanao Region
8- OFW
9- Contractual by job offer
2 – Unemployed (and other conditions such as: Senior, PWD, Retired and/or with Health condition)
3 – Minor (below majority of age 18y.o.)
1
a. Type of Family:
Based on composition:
(✔) Nuclear ( ) Extended ( ) Dyad ( ) Single- parent ( ) Homosexual/Same Sex ( ) Cohabiting/Communal
Based on locus of power
( ) Patrifocal/Patriarchal ( ) Matrifocal/Matriarchal (✔) Egalitarian ( ) Matricentric
Based on place of residence
(✔) Patrilocal ( ) Matrilocal ( ) Bilocal (Ambilocal) ( ) Neolocal
Based on descent
(✔) Patrilineal ( ) Matrilineal ( ) Bilateral
b. Dialect Frequently used: Tagalog
2. Economic Indicator:
A. How many Income earners per family(ies)? Earner 1 : Family position: Husband Php 750
Earner 2 : Family position: _ Php
Earner 3 : Family position: Php
Earner 4 : Family position: Php
3. Cultural Indicator:
A. Cultural Orientation regarding Illness (Multiple Response)
( ) believe that illness is caused by physiologic factor e. g. infection
( ) believe that illness is caused by supernatural phenomenon e. g. kulam, balis ( )
believe that illness is a punishment from GOD
( ) believe that illness is caused by other person
(✔) believe that illness is caused by change in weather
( ) others: believe that illness is caused by food
C. Cultural Perception
( ) always practices local cultural practices about health matters
(✔) sometimes practices local cultural practices about health matters ( )
does not practice any local cultural practices about health matters
D. Community Involvement
2
(✔) Actively join fiesta, religious procession, local cultural practices ( ) does not actively join
4. Environmental Indicator
A. Home
a. Ownership: ( ) Owned (✔) Rented ( ) Rent- free ( ) Least to own
( ) squatting/informal settlers ( ) professional squatters
b. Construction materials used: ( ) Light ( ) Mixed (✔) Strong (Concrete)
c. Number of rooms used for sleeping:( )1 ()2 ()3 ()4 ()5
(✔) None (no partition)
d. Adequacy of space: (✔) Adequate ( ) Inadequate
e. Lighting facility: (✔) Electricity ( ) Kerosene ( ) Others, specify:
f. Adequacy of Lighting: ( ) Adequate (✔) Inadequate
g. Ventilation: ( ) Adequate (✔) Inadequate
h. General Sanitary condition: ( ) Generally clean (✔) Dirty
B. Water Supply:
a. Ownership: (✔) Private ( ) Public
b. Water Source: NOTE: If deep well, proceed to letter “e”.
Cooking: ( ) Deep well (✔) Local Water District ( ) Commercial ( ) Others:
Drinking: ( ) Deep well ( ) Local Water District (✔) Commercial ( ) Others:
Bathing/CR/Flushing: ( ) Deep well (✔) Local Water District ( ) Commercial ( ) Others:
D. Waste Disposal:
a. Refuse and Garbage
1. Storage: (✔) Container ( ) None
2. Waste Segregation: (✔) Practiced ( ) Not Practiced
2.1 If practiced, method of disposal:
( ) Hog-feeding ( ) Open dumping ( ) Burial in pit
(✔) Collected ( ) Composting ( ) Open burning
2.2 Reason for practicing:
(✔) Environmentally friendly (✔) Barangay ordinance which is strictly monitored
(✔) Use for business ( ) Others, specify:
2.3 If not practiced, method of disposal:
( ) Hog-feeding ( ) Open dumping ( ) Burial in pit
( ) Collected ( ) Composting ( ) Open burning
2.4 Reason for not practicing
( ) Not aware of effects ( ) No time to do it
( ) Long-time practice of family ( ) No barangay/municipality ordinance
b. Toilet Facilities:
1. Ownership: (✔) Owned ( ) Shared/Public ( ) None
2. Type:
( ) “Ballot system” (✔) Pail system ( ) Overhung latrine ( ) Antipolo type
( ) Open-pit privy ( ) Closed pit privy ( ) Bored- hole latrine (
( ) Water- sealed ( ) Flush type ) None
3. Location from source of water: ( ) Less than 20 ft. ( (✔) 20 ft. beyond
4. Sanitary condition: ) Generally clean (✔) Dirty
3
b. Practices measures done to control insects/vectors of diseases:
( ) Fumigation (✔) Insecticides ( ) setting traps (✔) Cleaning the yard ( ) None
c. Presence of breeding sites ( for observation): (✔)
Yes ( ) No
1. LIFESTYLE PRACTICES
2. NUTRITIONAL STATUS
B. Dietary History
24- Hour Food Recall
Date Time of the day Food taken
BREAKFAST Fried rice, 1 egg, 2 hotdogs, 1 cup of coffee and 1 glass of water
SNACK 1 pc of Bread and 1 glass of water
LUNCH 1 rice, 1 serving of Sinigang na baboy and 2 glasses of water
SNACK 1 pc banana cue
DINNER 1 rice, 1 serving of adobong baboy and 1 glass of water
MIDNIGHTSNACK none
E. Reason for not choosing other options: ( ) Not healthy (✔) Own preference ( ) Not affordable
( ) personal belief/religious practices ( ) Health condition
F. From the above response, how frequent is the intake?( ✔) Everyday ( ) Twice a week ( ) Once a week
( ) Others, specify:
G. How is food prepared for mealtime? (✔) Prepared at home ( ) Bought outside
H. How often? (✔) Everyday ( ) Twice a week ( ) Once a week ( ) Others, specify:
4
I. If bought outside, is it from the: ( ) Restaurant/Fast food (✔) Carinderia
( ) Food cart e.g. Fried chicken sa kanto, provent, calamares
L. Takes/eat grilled foods: ( ) Everyday ( ) Every other day ( ) Every week ( ) Sometimes (✔) Never
A. Person/nel mostly consulted in times of sickness/illness: (✔) Doctor ( ) Nurse ( ) Midwife (✔) Hilot
( ) Albularyo ( ) Faith Healer ( ) Elderly
B. Measures taken in times of sickness/illness: (✔) Consult a private health worker ( ) See a known community healer
(✔) Consult a Rural Health Team ( ) Self- Medication ( ) None
C. Medication/ treatment taken in times of sickness/illness: (✔) Prescribed by Doctor (✔) Self-Medication/OTC drugs
(✔) Herbals ( ) Others, specify:
D. Medical Check-Up whether in private or government institution: (✔) once a year ( ) twice a year ( ) more than a year
E. Dental Check-Up whether in private or government clinic: ( ) once a year ( ) twice a year (✔) more than a year
A. What are the Health Services available in the barangay health center? Immunizations and Medicines
B. Immunization record
Incom Fully
Age Complete
DPT DPT DPT Hepa B Hepa B Hepa B OPV OPV OPV Meas plete Immun
Name in Gender BCG according
1 2 3 1 2 3 1 2 3 les accdg ized
mos to Age
to Age Child
D. Family Planning [only for: Women who are 12 yrs. (menarche age) to 40-45 yrs. (until menopause age); with partner(s); or plans
to get pregnant.]
( ) b. Fertility Awareness-Based Method Like: ( ) Cervical Mucus/Billings Ovu.Method ( ) Basal Body Temperature
( ) Sympto-thermal Method ( ) Standard Days Method (
) Lactational Amenorrhea Method
5. HEALTH INDICATORS
A. Morbidity
Intervention
Name Age Gender Cause With Without Admitted Not Admitted
Lorena Pangan 33 F Mild cerebral palsy
✔
Aidelle Isaac 7 M Bronchial Asthma Nebulizer ✔
5
C. History/ Presence of Non Communicable Disease in the Family
Name Age Gender NCD
IV. Health Resource: (Key Informant interview with the Barangay Officials)
1. Manpower Resources
2. Material Resources
A. Health and Budget Expenditures: ( ) Available ( ) Not-Available Amount per year: Php
B. Availability of supplies and equipment: ( ) Available100% ( ) Limited Supplies ( ) Not-Available
1. Recognized Leaders:
Formal/Elected: (✔) Captain ( ) Kagawad
Non-formal: ( ) Elderly ( ) BHW (✔) Influential person
( ) Religious leader ( ) Neighbor
2. Conditions/ events/ issues that cause social conflicts/ upheavals within the community
(✔) Gossip (✔) Family conflict ( ) Drugs ( ) Riot (✔) Alcohol drinking
(✔) Others, specify:
3. Practices/ approaches which are effective in setting issues and concern within the community (✔)
Settlement among involved parties (✔) Brgy. hearing ( ) Endorsed to local police
( ) Others, specify:
VI. Any concerns/suggestions regarding the life style you have in the area in general.
The road is narrow