SITIO: _________________________ SOCIO-ECONOMIC PROFILE A) Household Composition 1) Age Range according to Sex Age Range Male 0-1 year

old 2-6 years old 7-12 years old 13-17 years old 18-35 years old 36-60 years old 61-70 years old Above 70 years old 2) Civil Status Civil Status Single Married Widowed 3) Religion Religion Roman Catholic Iglesia ni Cristo Protestant (Anglican, Baptist, Lutheran, Methodist, Pentecostal, Presbyterian, Episcopal) Restorationist (Jehovahs Witnesses, Seventh-Day Adventist) Pagan 4) Educational Attainment Educational Attainment Below 18 years old Pre-school Elementary undergraduate Elementary graduate High school undergraduate High school graduate Vocational graduate College undergraduate College graduate Post-Tertiary None I.

Female

18 years and above

5) Occupation Occupation Agricultural (farmer) Mining (miner) Mechanical (mechanic, welder) Business & Industrial (entrepreneur, baker, tailor, storekeeper) Health (midwife, nurse) Processing, Manufacturing & Structural (labourer, carpenter, construction worker, engineer) Social, Government, Public Works (government employee, guard, networking employee) Trades & Transport (driver) OFW Unemployed Others 6) Monthly Income Income Range 1,000 & below 1,000-5,000 6,000-10,000 10,000 & above 7) Type of Family according to Organization/Members Type Nuclear Extended Blended 8) Type of Family according to Authority Type Patriarchal Matriarchal Egalitarian Matricentric B) Dwelling Unit 1) Type of Housing Unit Type Concrete Concrete & Wood Wood & G.I. Makeshift

2) Status of Occupancy (housing unit) Status Owned Rented Others 3) Appliances in the House Appliance Refrigeration equipment (Refrigerator, Freezer) Stoves Cooking equipment (Microwave Oven, Oven Toaster, Rice Cooker) Washing equipment (Washing Machine, Dryer) Television CD/DVD Player Computer (Desktop, Laptop) Radio Electric fan Others 4) Source/s of Lighting Source Electricity LPG Kerosene Wood Electricity & Kerosene Electricity & Wood Others 5) Materials for Cooking Material Electricity LPG Kerosene Wood LPG & Kerosene LPG & Wood Others 6) Lot Ownership Type Owned Rented Others

II.

HEALTH STATUS OF CHILDREN 0-6 YEARS OLD 1) Childs Birth Attendant Attendant

Physician Midwife Health team member BHW Family member Hilot Others 2) Place of Delivery Place Hospital Home Clinic Others 3) Breastfeeding of Child for 6 months or more 6 months or more Yes No 4) Reasons for Breastfeeding Reason Nutrition Proper Growth & Development Others 5) Immunization Status Status Fully Immunized Not Fully Immunized Not Immunized MATERNAL HEALTH A) Immunization 1) Tetanus Toxoid Immunization Status Status Fully Immunized Not Fully Immunized Not Immunized III.

2) Place of Immunization Place Hospital Barangay Health Center Private Clinic B) Prenatal Care 1) Availing of Prenatal Care Prenatal Care Yes No 2) Place of Consultation Place Hospital Barangay Health Center Private Clinic 3) Attending Personnel Attendant Physician Midwife Nurse Hilot Others IV. Usage Yes No 2) Previous Use of Family Planning Usage Yes No FAMILY PLANNING 1) Present Use of Family Planning

3) Method Used Method Pills Bilateral Tubal Ligation Injectable Withdrawal

Abstinence Calendar method Condom Intra-Uterine Device Lactational Amenorrhea Method 4) Advising Personnel Personnel Physician Midwife Nurse Social Worker Hilot Others

5) Reason for Not Using any Family Planning Method Reason Personal (not interested, newlywed, single, separated) Intellectual/Perceptual (Knowledge deficit, Ineffective as perceived, Go yeah and multiply idea) Physiological (Infertility, Extremes of age, Ligation)

V.

GENERAL HEALTH PRACTICES 1) Place of Consultation Place

Hospital Barangay Health Center Private Clinic 2) Reason for Choice of Consultation Reason Financial reasons Reliability Proximity Efficiency of personnel Use of advanced technology ENVIRONMENTAL HEALTH 1) Main Source of Water Main Source Faucet Rainwater Spring VI.

Well Others 2) Water Storage Storage Tank Plastic Container Drum Bottle Drum & plastic container Drum & bottle Others 3) Toilet Facility Facility Water sealed (automatic flush) Closed Pit Open Pit Flush Type (use of tabo when flushing) 4) Garbage Disposal Facility Facility Open dumping Common pit Individual pit Burning Burning & individual pit Burning & open dumping Others 5) Drainage System System Open Blind (close) None Others 6) Domestic Animals Kind Farm animals (carabao, cow, pig, goat) Fishes (tilapia) Poultry (duck, chicken, goose) Pet animals (dog, cat, rabbit, guinea pig) Combination

VII.

MORBIDITY RECORD 1) Type of Illness

Disease Certain infectious and parasitic diseases (measles, typhoid, TB, asthma Cancer Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (anemia, fever) Endocrine, nutritional and metabolic diseases (goiter, DM) Diseases of the nervous system (convulsions) Diseases of the circulatory system (RHF, CVD, HPN) Diseases of the respiratory system (flu, pneumonia, cough, colds) Diseases of the digestive system (diarhhea, ulcer, tonsillitis, malnutrition, toothache) Diseases of the skin and subcutaneous tissue Diseases of the musculoskeletal system (arthritis) Diseases of the genitourinary system Pregnancy, childbirth and the puerperium Congenital malformations, deformations and chromosomal abnormalities Injury, poisoning and certain other consequences of external causes 2) Therapeutics administered/advised/done Therapeutics Medication Hospitalization Herbal Medicine Use Rest Water therapy None 3) Treating Personnel Attendant Physician Midwife Health Team Member Family Member Hilot Self-Treatment Others 4) Efficiency of Treatments Sought Efficiency Effective Not Effective VIII. PERCEIVED COMMUNITY HEALTH PROBLEMS

1) Major Community Health Problems Major classification Subclassifications Illness problem Certain infectious and parasitic diseases (measles, typhoid, TB, asthma) Cancer Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (anemia, fever) Endocrine, nutritional and metabolic diseases (goiter, DM) Diseases of the nervous system (convulsions) Diseases of the circulatory system (RHF, CVD, HPN) Diseases of the respiratory system (flu, pneumonia, cough, colds) Diseases of the digestive system (diarhhea, ulcer, tonsillitis, malnutrition, toothache) Diseases of the skin and subcutaneous tissue Diseases of the musculoskeletal system (arthritis) Diseases of the genitourinary system Pregnancy, childbirth and the puerperium Congenital malformations, deformations and chromosomal abnormalities Injury, poisoning and certain other consequences of external causes Environmental problem Unsafe water Personal problem Work prioritization Problems regarding Insufficient medical supply government service

2) Suggested Solutions to Problems Solution Lifestyle Modification (Proper diet & exercise, Keeping away from vices) Home Remedies (Boiling of water, Water therapy) Herbal Medicine Personal Health Enhancement (Personal Hygiene, Self-consciousness) Environmental Sanitation Rest Medications Seminars & Trainings IX. COMMUNITY IN GENERAL 1) General Sanitary Condition Condition

Good Bad

2) Housing Congestion Condition Congested Not Congested

3) Recreational Facilities Facility Sports facility (volleyball court, basketball court)

4) Availability of Health Care Facilities Availability Available Not Available