Respondent Characteristics

Name/ Head of the Family:

Sex:
Male

Female
Civil Status:
Single
Married
Widowed
Monthly Household
Income:
1,000 5, 000
5,001 10,000
10, 001- 15,
000
15,001
20,000
20,001 25,
000
25, 001
30,000
30,000 and
above

Age:

Address:

Educational
Attainment:
College
Graduate
College Level
High School
Graduate
High School
Level
Elementary
Graduate
Elementary
Level
Vocational
course

Occupation:
Family History
Does the patient have first degree relative
with:
YES
NO
Hypertension
Stroke
Heart Attack
Diabetes
Asthma
Cancer

Questionnaire to Determine Probable Angina, Heart

Attack, Stroke or Transient Ischemic Attack
YES
NO
Kidney
Disease
Angina or Heart Attack
1. Have youHealth
had Measurements
any pain or
Obesity
discomfort or any BMI:
pressure or
Ht (cm):
Yes
heaviness
in
your
chest?
No
(Nakararamdam
ka
po
bang
Central
Adiposity
Waist
Circumference
:
pananakit o kabigatan ng dibdib)

Yes

2. Do you get the pain in the center of

No or left chest or left arm?
the chest
Raised
BP ba ay nasa gitna
1st reading:
(Ang sakit
ng
nd
2
reading:
Yes
bahagi o sa
dibdib,
sa kaliwang
Average BP:
No
kaliwang braso )
3. Do you
get it when
you walk
Presence
or Absence
of Diabetes
uphill
or patient
hurry? diagnosed
(Nagmamadali
o diabetes?
1. Was
as having
Yes nang mabilis
No

naglalakad
paakyat?)
Do not know
4. Do you slow
down if you get the
with medications
pain while
walking?
(Tumitigil
without
medications
2.
Does
patient
have
the following symptoms?
ka bas a paglalakad kapag
Polyphagia
(frequent
eating)
sumakit
ang iyong
dibdib?)

Polydipsia
(frequent
thirst
)
5. Does the pain go away if you
Polyuria
urination)
stand
still or(frequent
if you take
a tablet
under the tongue? (Nawawala
ba ang sakit kapag ikaw a y di
kumilos o kapag naglagay ka ng
gamot sa ilalim ng iyong dila?)
6. Does the pain go away in less
than 10 minutes? (Nawawala ba
ang sakit sa loob ng 10
minuto?)
7. Have you ever had a severe
chest pain across the front of
your chest lasting fo half an
hour or more? (Nakaramdam ka
nab a ng pananakit ng dibdib na
tumagal ng kalahating oras o
higit pa?)
Stroke and TIA
8. Have you ever had any of the
following: difficulty in talking,

Lifestyle
Smoking (Tobacco/ Cigarette)
Never smoked
Stopped > a year
Current smoker
Stopped < a year
Passive smoker
Alcohol Intake
Never consumed
Yes,
Drinks alcohol
YES
NO
Excessive Alcohol intake
In the past month, had 5
drinks in one occasion
High Fat/ High Salt Food
Intake
Eats processed/ fast foods
(e.g. instant noodles,
hamburgers, fires, fried
chicken skin, etc.) and ihaw
(e.g. isaw, adidas, etc. )
weekly
Dietary Fiber Intake
3 servings of vegetables
daily
2- 3 servings of fruits
daily
Physical Activity
Does at least 2 hours a
week of moderate- intensity
physical activity

Family Structure, Characteristics and Dynamics

Name of Household
Sex
Date of Birth
Member

M- Male

Age

Civil Status

S- Single

Religion

C- Catholic
M- Married

F- Female

Educational
Status

Occupational
Status

Occupation

EG- Elem Graduate

E- Employed
BA- Born Again
EU- Elem Undergraduate

U-

unemployed
W- Widowed
CL- Common Law
Se- Separated

INC- Iglesia ni Cristo

HG- High School Graduate

PT- Part time
HU- High School Undergraduate

Immunization Status of Target Age Group

Name

Age

BCG
1

DPT
2

OPV
2

Hepatitis B
2
3

AMV

Remarks
Incompl Compl
ete
ete