Windshield Survey Tool Tabulation

A. Family Structure, Characteristics and Dynamics F1 F2 F3 F4 F5 F6 F7 F8 F9 F10 Total

a. Nuclear
b. Extended
c. Matriarchal
d. Patriarchal
B. Socio-economic and Cultural Characteristics
1. Educational Attainment
a. College
b. High School
c. Elementary
d. Has not gone to school
e. Others: College Undergraduate
2. Employment Status
a. Employed
b. Unemployed
c. Self-employed
d. Others
3. Occupation
4. Monthly Income
a. Below 1k
b. Below 5k
c. Below 10k
d. Above 10k
e. Others, specify:
5. Religion
a. Roman Catholic
b. Protestant
c. Islam
d. Others, specify: INC, Born Again, Atheist, etc..
6. Dialect
a. Chavacano
 b. Bisaya
c. Tagalog
d. Tausug
e. Yakan
f. Ilonggo
g. Others, specify:
C. Home and Environment
1. Type of Housing Facilities
a. Concrete
b. Light Materials
c. Mixed
d. Others, specify:
2. Age
a. Old
b. Newly constructed
3. Ownership
a. Owned
b. Rented
c. Others, specify:
4. Adequacy of Living Space
a. 1 room
b. 2 rooms
c. 3 rooms
d. More than 3 rooms
e. Others, specify:
5. Living Room Availability
a. Present
b. Multipurpose
6. Presence of breeding/ resting sites of vectors of diseases
a. yes
b. no
7. Presence of accidental hazards
a. Detached
b. Broken windows
c. Broken stairs
d. Broken/ Missing walls
e. Leaks
f. Others, specify:
8. Food Sources
a. Market
b. Carinderia
c. Vegetable Garden
d. Others, specify:
9. Food Storage
a. Refrigerator
b. Kitchen Cabinets
c. Others, specify:
10. Cooking Facilities
a. Gas Stove
b. Rice cooker
c. Charcoal/Firewood use
d. Others, specify:
D. Water Supply
1. Sources
a. Faucet, connected to ZCWD
b. Artesian Well
c. Deep Well
d. Others, specify:
2. Storage
a. Refrigerator
b. Water jug/container
c. Water Dispenser
d. Others, specify:
E. Toilet Facilities
a. water-sealed
b. flush/water-sealed
c. antipolo style
d. ballot system
e. cat hole
f. pit privy
g. direct disposal in the bodies of water
h. communal
F. Garbage Disposal
a. Open burning
b. Composting
c. Open pit
d. City garbage collecting system
e. Others, specify:
G. Drainage System
a. Open
b. Close
H. Community Facilities
a. School Yard
b. Billiard Hall
c. Bingo Social Hall
d. Basketball Court
e. Minimart
f. Carinderia
g. Flea Market
h. Videoke Bar
i. Waiting Shed
j. Cemetery
k. Church/Chapel
l. Multipurpose Hall
m. Mini Bakery
I. Communication Facilities
a. Telephone
b. Television
c. Radio
d. DVD/CD Player
e. Cellular Phone
f. Computer with Internet
g. Newspapers/Magazines
h. Others, specify:
J. Transportation
a. Motorcycles
b. Pedicabs
c. Cars
d. Bus
e. Jeepney
f. Others, specify:
K. Health Status of each family Member
1. Common Illness
a. Cough
b. Colds
c. Diarrhea
d. Constipation
e. Skin diseases
f. Influenza
g. Tonsillitis
h. Others, specify:
2. Risk factors for lifestyle diseases
a. Hypertension
b. Physical Inactivity
c. Sedentary Lifestyle
d. Cigarette Smoking
e. Obesity
f. Elevated blood cholesterol
g. DM
h. Stress
i. Inadequate Fiber Intake
j. Alcohol drinking
k. Substance Abuse
l. Others, specify:
L. Values, Habits, Practices on Health Promotion, Maintenance and Disease Prevention
1. Health Seeking Behaviour
a. Family Doctor/Private Doctor
b. Hospital Doctor/ OPD
c. Health Center
d. Hilots
e. Quack Doctor
f. Self- medication
g. Others, specify:
2. Personal Habits/Practices
a. Walking barefooted
b. Smoking Cigarettes
c. Eating sidewalk foods
d. Eating Raw foods
e. Other, specify:
3. Immunization Status
a. Fully Immunized
b. Partially Immunized
c. Not Immunized
4. Infant Feeding Practices
a. Breastfeeding
b. Bottle-feeding
c. Others, specify: