HOUSEHOLD PROFILE

HH NO: _________________
⃝NHTS NO:___________________
⃝NON-NHTS

P R O F I L E ENVIRONMETAL STATUS
MEMBER A.HOUSING
TYPE VENTILATION
NAME RELATION TO FAM. HEAD SEX BIRTHDATE AGE OCCUPATION EDUC. A. R. C.S. M. E. REMARKS (HLT. STATUS) Ο strong (concrete) Ο well
Ο light (wood) Ο poor
1 Ο mixed LIGHTNING
Ο other (specify)
2 Ο well
ROOMS Ο poor
3
Ο1
4 Ο2 SOURCE
5 Ο 3 or more Ο electricity
Ο kerosene
6 OWNERSHIP Ο others (specify)
7 Ο rented
Ο owned OVERALL IMPRESSION OF THE
8 Ο others HOUSE (surveyor)
9 B.WATER __________________________
__________________________
10 1.Source of Water Supply
__________________________
Ο NAWASA
11 Ο deep well
__________________________
12 Ο water refilling station C. EXCRETAL DISPOSAL
If NAWASA: Ο owned Ο YES
13 Ο communal ___water sealed
0-59 MONTHS (0-5 YEARS OLD) OTHERS 2.Storage ___open pit
Ο container ___hanging toilet
NAME SEX WT HT TOF IMMUNIZATION EDUC. LEVEL PERSONAL HABITS EXERCISE ___flush
SMOKING
Ο covered
Ο YES ___other (specify)
Ο yes Ο no _______packs/day Ο uncovered
Ο NO 3. Distance from the house: Ο NO
___ “ballot” (wrap and throw)
ALCOHOL PREFERRED MEDICINE ________meters
___ others (specify)
Ο yes Ο no _______bottle/day Ο OTC D. DRAINAGE SYSTEM
Ο Prescribes Ο open
DRUGS Ο yes Ο no Ο Herbal Medicine Ο blind/ closed E. FOOD ESTABLISHMENT
CIVIL INVOLVEMENT Ο none Permit: YES ( ) NO ( )
Indicate name or none How is it? Establishment:
Organization/s: _________________ Ο good Ο sari-sari store
HEALTH CONDITION FOR THE PAST YEARS FAMILY PLANNING
Ο poor (specify)
Participation in Health Care Ο carinderia
NAME AILMENT D. OF OCCURENCE TX PRESENT CON. NAME:_____________________________
Action:________________________ F. GARBAGE DISPOSAL Ο ambulant vendor
Position in the Community/ METHOD:___________________________ Ο open pit Ο talipapa
Organization: __________________ TYPE OF CLIENT:_____________________ Ο burning Ο others (specify)
DECEASED FAMILY MEMBER Ο garbage collector G. COMMUNICATION FACILITIES
NAME CASED OF DEATH DATE DIED HEALTHCARE FACILITIES BELIEFS AND PRACTICES H. APPLIANCE OWNED
Ο BHS Ο YES ______________ ___________________________ I. ACCESSIBILITY TO
Ο Private Clinics ______________ ___________________________ COMMUNICATION FACILITY
Ο Hospitals Ο NO ___________________________ Ο hospital
NUTRITIONAL STATUS Ο market
FOOD PREFERENCE FOOD PREPARATION COMMUNITY PROBLEMS J. ANIMAL RAISED
Ο church
Ο vegetables Ο pork No. of meals/ day: Ο prepared at home Ο garbage disposal Ο domestic
Ο schools
Ο poultry Ο fish _________________________
Ο once Ο twice Ο thrice Ο four or more Ο street foods Ο relationship/ unity with their neighbors
Ο beverages Ο beef Ο instant meals Ο source of water Ο stray
_________________________
Ο water Ο soft drinks/ juices Ο bought (specify) Ο source of income