DEPARTMENT OF HEALTH

Regional Office II
Municipality of Tuao
HOUSEHOLD HEALTH PROFILE and HEALTH STATUS

DATE PROFILED/DATE VISITED:

1st quarter: ___________ 2nd Quarter: ____________ 3rd Quarter: _______________4th Quarter: ____________

NAME OF RESPONDENT (if wife, pls. indicate maiden name): ___________________________________________

Purok: Barangay: No. Of HH Members:
NHTS HOUSEHOLD: _____NHTS (4Ps) _____NHTS (Non-4Ps) _____Non-NHTS
HH HEAD Philhealth Membership: ___NO ___YES (CATEGORY____________)
Ethnicity: __IP/ __non-IP
Source/s of Water: __Level 1 (well)/ __Level2 (pump well) / __Level 3 (water system) / __Others
With access to safe water___ / With sanitary toilet___
Waste Disposal: __segregation/ __composting/ __recycling / __collected by MCDS/ __others (burning)

Name of
household
member

Relationship
to HH Head
Sex
Age
Birthday
Philhealth ID
No. Of HH
member ≥ 21
y/o
Classification 1st 2nd 3rd 4th 1st 2nd 3rd 4th 1st 2nd 3rd 4th 1st 2nd 3rd 4th 1st 2nd 3rd 4th 1st 2nd 3rd 4th
by
age/health
risk group
Medical __HPN __HPN __HPN __HPN __HPN __HPN
history __DM __DM __DM __DM __DM __DM
__BRONCHIAL __BRONCHIAL __BRONCHIAL __BRONCHIAL __BRONCHIAL __BRONCHIAL
ASTHMA ASTHMA ASTHMA ASTHMA ASTHMA ASTHMA
__CVD __CVD __CVD __CVD __CVD __CVD
__PTB __ PTB __ PTB __ PTB __ PTB __ PTB
(__symptomatic) (__symptomatic) (__symptomatic) (__symptomatic) (__symptomatic) (__symptomatic)
(__with DSSM) (__with DSSM) (__with DSSM) (__with DSSM) (__with DSSM) (__with DSSM)
(__on going tx) (__on going tx) (__on going tx) (__on going tx) (__on going tx) (__on going tx)
(__done tx) (__done tx) (__done tx) (__done tx) (__done tx) (__done tx)
__Mass (cyst) __Mass (cyst) __Mass (cyst) __Mass (cyst) __Mass (cyst) __Mass (cyst)

OTHER disease: OTHER disease: OTHER disease: OTHER disease: OTHER disease: OTHER disease:
______________ _____________ _____________ _____________ _____________ ______________
(__symptomatic) (__symptomatic) (__symptomatic) (__symptomatic) (__symptomatic) (__symptomatic)
(__on going tx) (__on going tx) (__on going tx) (__on going tx) (__on going tx) (__on going tx)
Medications

FP METHOD

Blood
pressure
Height

Weight

BMI =
[weight (kg)
/ height (cm)
/ height
(cm)]
x 10,000

PERSONS WITH DISABILITY

Mental/ Speech
Hearing Learning Musculo-skeletal Psychosocial Visual Others
Intellectual Impairment
Type of
disabilty
Medications

Registered
PWD (y/n)
NEWBORN
0-28 days BCG HEPA B NBS BF NUTRITIONAL STATUS CPAB
STUNTED WASTED SAM WASTED MAM N OW (TD2 for 1st
(severely UW) (UW) preg)

INFANTS
BCG PENTA OPV IPV PCV
1 2 3 1 2 3 1 2 3
29 days- 11 months

MCV1 MCV2 FIC NUTRITIONAL STATUS VIT. A EBF

S SAM MAM N OW
29 days- 11
months

UNDER 5
CIC DEWORMING VIT. A NUTRITIONAL STATUS

(13-24 MOS) S SAM MAM N OW

1-4.11Y/O
(12-59mos)
SCHOOL-AGED CHILD
DEWORMING NUTRITIONAL STATUS NO or INC VACC. REMARKS
S SAM MAM N OW
5-9 y/o

ADOLESCENT
DEWORMING NUTRITIONAL STATUS SMOKER ALCOHOL DRINKER
S SAM MAM N OW
10-19 years
old

PREGNANT WOMEN
No. of PW TD WITH WITH CaCO3 Birth Plan Undergone
FeSo4+FA Lab
10-14 y/o 15-19 y/o 20-49 y/o TD2 TD2+

15-49 y/o

POST-PARTUM
(42 days No. Of PP 4 2 PPV Complete Complete CaCO3 With FeSo4 Completed FeSo4 Vit. A Remarks
post ANC (w/in FeSo4 (180 (90 tabs/90 + FA (90 tabs) (within
pregnancy) 24hrs) tabs) days) 1month)
(w/in 7
days
15-49 y/o
 NON PREGNANT/PP
No. Of NP/PP FP USERS UNMET GIVEN IEC MENOPAUSE

SENIOR CITIZEN
No. Of Senior Citizen Given Pneumonia Vacc. Given FLU Vacc. Screened with Philpen
(60 years old and above) (1 dose/ lifetime) (1 dose/yearly)

Summary of findings& issues: REFERRED TO OTHER ACTIONS TAKEN

(please indicate name)

Assessed by NDP/RHMPP: Signature of Respondent:

RELATIONSHIP TO HH HEAD:
1 - Head BMI SCORE FOR ADULTS (page 1):
2 - Spouse N-18.5 to 24.9
3 - Son UW- below 18.5
4 - Daughter PRE OB (overweight)-25 to 29.9
OB1-30 to 34.9
5 - Others, specify relation
OB2- 35 to 39.9
OB3- 40 above
CLASSIFICATION BY AGE/HEALTH RISK GROUP
(page 1):
N-Newborn (0-28 days)
AP-Adolescent-Pregnant
I-Infant (29 days-11 mos old)
PP-Post Partum
U-Under-five (1-4 years old)
WRA-15 to 49 years old, not pregnant and non PP
S-School-Aged Children (5-9 y.o.)
A-Adolescents (10-19 years old)
SC-Senior Citizen
P-Pregnant
PWD-Persons with Disability
AB-Adult 25-59 y/o

NUTRITIONAL STATUS OF INFANTS (page 3):

S-Stunted
Wasted SAM– severely UW
Wasted MAM – underweight
N- Normal
OW- overweight