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QUESTIONNAIRE

Family Structure, Characteristics and Dynamics and Socio-Economic Status

Name Age/Sex Relationship EducationalAttainment

>8 yrs. oldCan read or

write

>18 yrs. old

Civil Status Religion

Length of residencyin the barangay

>18 yrs. old If employed,Monthly IncomePlace of origin Employed/Specify

Type of Family

Nuclear Family Extended

Family

Single Parent

Family

Dyad Family Cohabitation

Home and Environment

Lot

Rented Owned Others (Specify) _________

House

Rented Owned Others (Specify) _________

Type of House

Concrete Wood Mixed Makeshift Others (Specify) _________

Environment

Lighting

Adequate Inadequate

Ventilation

Adequate Inadequate

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Water Supply

Level 1(Point Source)Protected or deepwell > 250 m away

Level 2(Communal FaucetSystem)Protected or deepwell < 25 m away

Level 3(WaterworksSystem)Piped distributionand householdtaps

Others (Specify) _________

Excreta Disposal

Sanitary Toilet Facility Unsanitary Toilet Facility No Toilet Facility

Garbage/ Solid Waste/ Refuse Disposal

Open Dumping Burying Collected Burning Others (Specify) _________

How far away from household? _________

Pet Ownership/ Domesticated Animals

If any (Specify) _________ How far away from household? _________

Pet/ Domesticated Animals Food Source

If any (Specify) _________

Health Status and Values, Habits and Practices on Health Promotion,

Maintenance and Disease Prevention

Food Storage

Covered Uncovered Refrigerated Others (Specify) _________

Water Storage

Covered Uncovered Refrigerated Others (Specify) _________

Is there an infant?

Yes No (Skip Next 2 Questions)

Infant Feeding

Exclusive Breastfeeding Formula Mixed/ Specific Formula _________

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Immunization Status

BCG DPT 1 OPV 1 Hepatitis B 1 AMV

DPT 2 OPV 2 Hepatitis B 2

DPT 3 OPV 3 Hepatitis B 3

Health Seeking Behaviors

Common Illness for the past 6 months, Specify ________________

Common Illness for the past 1 year, Specify ________________

Where did you seek health care?

Barangay Health Center None

Private Clinic

Hospital Public Private Others (Specify) _________

Nearest Health Center Facilities _________________________________

Nearest Government Hospital _________________________________

Nearest Public School _________________________________

Nearest Public Transportation Terminal _________________________________

Communication

Where do you get health information from?

Health Center Personnel Newspapers/ Fliers/ Posters Radio

Television Phone Others (Specify) _________

Family Planning

Are you practicing family planning?

Yes No (Skip Next Question)

What methods are you using?

Temporary (Pills, Condoms, IUD, Diaphragm, Cervical Cap)

Permanent (Tubal Ligation, Vasectomy)

Pregnant Mother

Are you pregnant? Yes No (Skip Next Question)

Prenatal Check-up ___________________________________