GENERAL CHECKLIST

a. Population Distribution
AGE GROUP FREQUENCY
0-12 months
1-4 years old
5-9 years old 7
10-14 years old 2
15-19 years old 2
20-24 years old 3
25-29 years old 1
30-34 years old 2
35-39 years old 5
40-44 years old 1
45-49 years old 1
50-54 years old 3
55-59 years old
60-64 years old 2
65-69 years old 1
70-74 years old
75-79 years old 1
80 and above

b. Dependency Ratio
Age Group TOTAL
Age 0-14 13
Age 65 and above 2
TOTAL

Age 15-64 (Economically Productive) 24

c. Body Mass Index (>18 years old)

BMI FREQUENCY
Underweight
Normal 8
Overweight
Obese

d. Blood Pressure Monitoring

BLOOD PRESSURE FREQUENCY
Normal 9
Prehypertension 3
Stage 1 Hypertension 2
Stage 2 Hypertension

e. Monthly Income or Salary per Household

Monthly Income/Salary Total Number of Household
Below 1, 000
1,100-5,000 1
5,001-10,000 2
Above 10, 000 4
TOTAL

f. Source of Monthly Income or Salary per Household

Source of Income Frequency Percent
Salary 5
Business 3
Landholdings
Pension 1
Others
- From Children
- From Relatives
- Remittance
- Self-employed

g. Health Status
Preferred choice for treatment Frequency
Private Hospital 1
Government Hospital 4
Private Doctor 2
Hilot / Herbolario 4
Self-care / Self-medicate 2
Others

Sick during past 3 months Frequency

Above 5
4-5
3 1
2 2
1 1
None 2

h. Socio-economic
House Property Frequency
Owned 6
Rented but not paying 1
Rented with pay

Type of building material Frequency

Concrete 2
Wood 1
Nipa 1
Mixed 4

i. Socio-cultural
Usual source of information Frequency
TV 6
Radio 4
Newspaper
Internet 4
Neighbors
others
Usual means of relaxation Frequency
Sports 1
TV / Movies 6
Computer 2
Gambling 1
Sleeping 5
Others 1

j. Family
Decision-making Frequency
Husband 2
Wife 1
Both 4
Others

Financial support Frequency

Husband 3
Wife
Both 4
Others

Type of Household Frequency

Nuclear 6
Extended 1
Blended

House materials used Frequency

Light materials 1
Strong materials 2
Mixed 6

Number of storeys Frequency

>2
2 1
1 5

Number of rooms Frequency

5
4
3 2
2 1
1 4
Others

Distance from neighborhood Frequency

>21 meters
11-20 m 2
7-10 m
4-6 2
1-3 3
Light source Frequency
Electricity 7
Generator
Petromax
Lamp 2
Gasul 2
Car battery
Candles 1
others

Water source for drinking Frequency

Deep well
Jetmatic pump 1
NAWASA
Spring
Rainwater
River
Water refilling station 7
Others

Water source for cleaning Frequency

Deep well 1
Jetmatic pump 7
NAWASA
Spring
Rainwater
River
Water refilling station
Others

Distance from water source to comfort room Frequency

>13 meters 5
10-12 m 1
7-9 m 1
4-6 m
1-3 m

Owner of water source for drinking Frequency

Personal
Neighbor
Common
Bought outside 7
Others

Owner of water source for cleaning Frequency

Personal 4
Neighbor 2
Common 1
Bought outside
Others
Disposal of water waste Frequency
Pipes 1
River / streams
Canal 5
Below house sinks 2
Pit with cover
Pit without cover
Seaside
Farm
Others

Type of Toilet used Frequency

Antipolo, covered 1

Antipolo, not covered 1

Water sealed 3

Automatic flush 2

Others

Means of solid waste disposal Frequency

Burying
Compost pit 5
Garbage collection
Burning 4
Reckless throwing
Others

Means of cooking Frequency

Wood 4
Charcoal 1
LPG 3
Electricity
Labhang
Bagaso
Gas 1
others

Number of meals per day Frequency

3 7
2
1
Others

Usual viand Frequency

Fish 6
Pork 5
Dried fish 4
Vegetables 5
Beef 2
Seafoods 1
Chicken 5
Others

Utensils used Frequency

Spoon
Fork
Both spoon and fork 7
Bare hands 4
others

Means of keeping excess food Frequency

Basket 2
Refrigerator 4
Cabinet 2
Kaldero 2
Covering 3
others

Animals present at home and at farm Frequency

Dog 5
Cat 3
Chicken 6
Pig
Goat
Horse
Cow 1
Carabao
Duck 2
Goose
Others (dragon)

Animal vaccination Frequency

Yes 6
No 1

Plants at home Frequency

Vegetables 2
Flowers 7
Trees 7
Herbs, medicinal plants 4

Key persons to consult in case of conflict Frequency

Mayor
Brgy. Officials 7
Police station
BHW 2
others
K. Social indices
Source of information Frequency
Radio 3
TV 6
Newspaper
Neighbors (na chismosa) 1
Magazine
Comics
Internet 2
Others

Family’s leisure time Frequency

TV / video 7
Radio 3
Computer 3
Newspaper / magazine
Sports 1
Movies 1
Gambling (specify) 1
None
Others 2

Mobiles owned Frequency

Car 2
Jeep
Tricycle 2
Bicycle 2
Van
Trisikad
None 1
Others 3

L. Health status
a) List down all diseases / illnesses incurred
 Cough
 Colds
 Flu
 Fever
 Tuberculosis
 Dengue
 Pneumonia
 Boil (Uyapos)
 Hypertension
b) List down all deceased members of the family within a year ago
Means of treatment Frequency
Herbal
Medical / Pharmacy 4
Combination 3
None
others