Davao Medical School Foundation Department

of Community & Family Medicine Community

Medicine IV

HOUSEHOLD SURVEY QUESTIONNAIRE

Respondent 1 Respondent 2 Respondent 3 Respondent 4 Respondent 5

Munisipalidad/Distrito Crossing Matina Aplaya Km 10
Barangay Brgy 22-c p Sasa
Purok piapi boulevard
Household # Blk 12
Date of Interview 8/7/2020 8/7/2020 8/8/2020

I. BASIC HOUSEHOLD IDENTIFICATION/INFORMATION

Name Age Educational Ethnicity Religion Occupati Marital status Personal Income/Day
Attainment on
Husband 1: JOVELON DIVA 15 FILIPINO ROMAN MATADERO Single 700-1500 php
CATHOLIC
Wife 1: JULIET REBUSA SERATO 16 ELEMENTARY FILIPINO ROMAN Single X
CATHOLIC
Husband 2: X
Wife 2: CHERRY MARIE CURAY 19 Grade 11 CHRISTIAN STUDENT X
Husband 3: X
Wife 3: WELYN JANE ORCIA 16 Grade 6 FILIPINO ROMAN X Single
CATHOLIC
Husband 4:
Wife 4:
Husband 5:
Wife 5:

CHILDREN IN THE HOUSEHOLD

Name of Child Birthdate Age Sex In Educational Name of Child Birthdate Age Sex In Educational
Household 1 school? Attainment Household 4 school? Attainment
1. ASHLEY SERATO 9 F NO 1.
2. JERILTON SERATO 11 M NO 2.
3. ANTHONY SERATO 6 M NO 3.
4. JAMES SERATO 1 yo M NO 4.
5. PRINCESS SERATO 1 yo F NO 5.
6. ANA MAE SERATO YES GRADE 6
 Name of Child Birthdate Age Sex In Educational Name of Child Birthdate Age Sex In Educational
Household 2 school? Attainment Household 5 school? Attainment
1. JOHNNY CURAY NOV 19 15 YES GRADE 9 1.
2003
2. JOHN MADEL FEB 19 2008 12 YES GRADE 6 2.
CURAY
3. KIM CURAY AUG 19, 9 YES GRADE 4 3.
2010
4. MADELINE JANE NOV 17, 4 NO 4.
CURAY 2015
5. JAMES LIAN AUG 5, 2013 7 YES KINDER 5.
CURAY
6. CADENCE JAN 6, 2019 1 F
MAXPEIN
MARSHAL
7.ALEXNDRIA CURAY MAY 24, 2
2020 MOS

Name of Child Birthdate Age Sex In Educational

Household 3 school? Attainment
1. WILSENE ORCIA MAY 15, 13 F YES GRADE 4
2007
2. WENDY ORCIA AUG 1, 2008 12 F YES GRADE 4
3. WARREN ORCIA MAY 7, 11 M YES GRADE 3
2009
4. NATALIE SECUYA JUL 21, 20182 F NO
5. CASSANDRA AUG 18, 11 F NO
ORCIA 2019 MOS
OTHER ADULTS IN THE HOUSEHOLD
Household 1 Relation Age Sex Educational Marital Occupation Personal
Attainment status Income/Day
1. ANGEL SERATO SISTER 23 F ELEMENTARY SINGLE
GRADE 6
2. ARIEL SERATO SISTER 32 F GRADE 9 SINGLE
3. EVALINE SERATO SISTER 21 F GRADE 7 SINGLE
4. MARK JOHN RIVERA BROTHER IN 26 M SINGLE
LAW
5. ANGEL SERATO SISTER 23 F ELEMENTARY SINGLE
GRADE 6
Household 2 Relation Age Sex Educational Marital Occupation Personal
Attainment status Income/Day
1. MADELINE CURAY MOTHER 44 F VOCATIONAL MARRIED BRGY NUTRITION “HONORARIUM”
SCHOLAR 2000 PER MONTH
2. JANNYLYN CURAY SISTER 26 HIGHSCHOOL SINGLE TRAINEE 300-350 php
3. STEPHANIE CURAY SISTER 22 ELEMENTARY SINGLE
4.
5.
Household 3 Relation Age Sex Educational Marital Occupation Personal
Attainment status Income/Day
1. WILMA ORCIA SISTER 20 F GRADE 7 MARRIED FILER 500
2. WILMER ORCIA BROTHER 24 M GRADE 1 SINGLE TIG BIRA UG 2,500
COTAINER
3. RENATO SECUYA BROTHER IN 20 M GRADE 6 MARRIED FILER 500
LAW
4. WILMA ORCIA SISTER 20 F GRADE 7 MARRIED FILER 500
5. WILMER ORCIA BROTHER 24 M GRADE 1 SINGLE TIG BIRA UG 2,500
COTAINER
Household 4 Relation Age Sex Educational Marital Occupation Personal
Attainment status Income/Day
1.
2.
3.
4.
5.
Household 5 Relation Age Sex Educational Marital Occupation Personal
Attainment status Income/Day
1.
2.
 3.
4.
5.

II. ECONOMIC INDICES

1. What is the main source of income for the family?
R1 R2 R3 R4 R5
Farming
OFW ✔️(SISTER)
Regular job (specify) ✔️
Others (specify) ✔️
HONORARIUM
“4 p’s”

2. How much is the accumulated income of the family per month?

R1 R2 R3 R4 R5
0-999
1000-2999 ✔️
3000-4999 ✔️
5000-6999
7000-9999 ✔️
10,000-above

3. Household appliances

R1 R2 R3 R4 R5
Refrigerator/Freezer
TV ✔️ ✔️
Aircon
Electric fan ✔️ ✔️
Radio/Cassette
Others (specify) RICE COOKER
 4. Vehicle ownership
R1 R2 R3 R4 R5
Truck ✖️ ✖️ ✖️
Jeep ✖️ ✖️ ✖️
Car ✖️ ✖️ ✔️
Motorcycle ✖️ ✔️ ✖️
Others

5. House ownership
R1 R2 R3 R4 R5
Owned ✔️ ✔️
Rented ✔️
Caretaker/free
Others

6. Materials used for the house

R1 R2 R3 R4 R5
Floor: WOOD WOOD WOOD
Cement/Wood/Bamboo/
Earth
Walls: WOOD WOOD WOOD
Cement/Brick/Wood/Bamb
oo
Roof: CEMENT WOOD WOOD
Cement/Wood/Bamboo/Pl
astic

7. What is the estimated lot area of your residence?

✖️ 50 SQ METER 50 SQ METER

8. What is the estimated floor area of your house?

✖️ ✖️ ✖️

9. Source of electricity?

R1 R2 R3 R4 R5
None
Davao Light ✔️ ✔️ ✔️
Own generator
Barangay generator
 Solar
Battery

10. How much do is your monthly electricity bill?

✖️ 500 300-400

11. Toilet
R1 R2 R3 R4 R5
None
Own toilet ✔️
Shared with other families ✔️ ✔️
What kind of toilet
Water sealed
Flush (buhos) type ✔️ ✔️
Pit with cover
Open pit ✔️

12. Transportation: how do you get to the main road or highway? (Check all needed modes of transportation)
R1 R2 R3 R4 R5
Walk ✔️ ✔️
Motorcycle
Tricycle ✔️ ✔️
Jeep ✔️
Bus
Others

13. On a usual day, how much do you spend for transportation as a family?
100-150 ✖️
III. ENVIRONMENTAL INDICES
1. Source of water for drinking and cooking
R1 R2 R3 R4 R5
Rain

Spring
Dug well
Peddler
Piped water system: ✔️ ✔️ ✔️
Level 2/Level 3

2. How much is your monthly water expenses?

500 200 150
IV. Solid waste disposal (check appropriate box)
Household 1 CENRO Recycle Bury Burn Throw in Others Household 4 CENRO Recycle Bury Burn Throw in Others
vacant lot (specify) vacant lot (specify)
Yard waste ✔️ Yard waste
Food waste ✔️ Food waste
Paper waste ✔️ Paper waste
Plastic waste ✔️ Plastic waste
Metal ✔️ Metal
Glass/bottles ✔️ Glass/bottles
Others Others
Household 2 CENRO Recycle Bury Burn Throw in Others Household 5 CENRO Recycle Bury Burn Throw in Others
vacant lot (specify) vacant lot (specify)
Yard waste ✔️ Yard waste
Food waste ✔️ Food waste
Paper waste ✔️ Paper waste
Plastic waste ✔️ Plastic waste
Metal ✔️ Metal
Glass/bottles ✔️ Glass/bottles
Others Others
Household 3 CENRO Recycle Bury Burn Throw in Others
vacant lot (specify)
Yard waste ✔️
Food waste ✔️
Paper waste ✔️
Plastic waste ✔️
Metal ✔️
Glass/bottles ✔️
Others
V. SOCIAL / CULTURAL INDICES

1. How far are the nearest schools (in kilometers)?

R1 R2 R3 R4 R5
Early childhood ✖️ 2km ✖️
Elementary (Grades 1-6) 1km 2km LESS THAN 1km
Junior high (Grades 7-10) 2km 2km 3km
Senior high (Grades 11-12) 2km 2km 3km
College 5km 10km 10m

2. How far is the nearest place of worship for your religion (in kilometers)?
1km LESS THAN 1km LESS THAN 1km

3. Forms of recreation as a family

R1 R2 R3 R4 R5
Picnic
Beach ✔️
Sports
Videoke ✔️ ✔️
Gambling
TV/movie ✔️
Social media ✔️ ✔️
None

4. Participation in community activities

R1 R2 R3 R4 R5
Fiesta
Sports tournaments
Dance events
Contests
Gambling
Others (specify) BIRTHDAY CELEBS
None, we don’t join ✔️ ✔️

VI.POLITICAL INDICES
1. How far is the barangay hall from your place (in kilometers)?
LESS THAN 1km LESS THAN 3km LESS THAN 1km
 2. How far is the nearest town/city hall (in kilometers)?
7km 5km 6km

3. Yes/No: Is anybody in your family holding any government position?

YES YES NO
If yes, who and what position?
R1 R2 R3 R4 R5
Name/Relation SISTER MOTHER ✖️
Position VOLUNTEER HONORARIUM

4. Yes/No: Did you vote in the last elections? If no, why not? Please indicate.
NO,UNDERAGE NO, NOT IN DAVA NO, UNDERAGE

VII.HEALTH INDICES
MORBIDITY AND MORTALITY
A. Health services
How far is the nearest doctor (in kilometers)?

What is the nearest hospital?

Name SPH ALEXIAN SPMC
Level of service
Distance from 2km 4km 4km
respondent’s house

Health centers
Distance LESS THAN 1km 1km 1KM
Services (pls check)
Checkup/consultation
Free medicines ✔️ ✔️ ✔️
Immunizations ✔️ ✔️ ✔️
Family planning ✔️ ✔️ ✔️
Others (specify) PRENATAL CHECK PRENATAL CHECK UPS PRENATAL CHECK UPS
UPS

B. Causes of Morbidity
Does anyone in the household have a long-term or chronic disease? If yes, fill the table below.
Name/Relation Age Diagnosis/Year diagnosed On maintenance? With physician? Monthly expenses
1.✖️
Household 1 2.
3.
1. CHERRY CURAY 19 OVARIAN CYST/2019 YES YES ✖️
Household 2 2.
3.
1. ✖️
Household 3 2.
3.
1.
Household 4 2.
3.
1.
Household 5 2.
3.

Did anyone in the household get sick in the past 12 months? If yes, fill the 2 tables below.
Was he/she seen by a health professional? If yes, fill the table below.
Name/Relation Age Diagnosis/Year diagnosed Treatment Who was Outcome
consulted?
1.✖️
2.
Household 1 3.
4.
5.
1.✖️
2.
Household 2 3.
4.
5.
1.✖️
2.
Household 3 3.
4.
5.
 1.
2.
Household 4 3.
4.
5.
1.
2.
Household 5 3.
4.
5.

If not seen by a health professional, fill the table below. Indicate the signs and symptoms, treatment done and who gave the treatment.
Name/Relation Age Sxs Treatment Who was Outcome
consulted?
1.✖️
2.
Household 1 3.
4.
5.
1.✖️
2.
Household 2 3.
4.
5.
1.✖️
2.
Household 3 3.
4.
5.
1.
2.
Household 4 3.
4.
5.
 1.
2.
Household 5 3.
4.
5.

C. Causes of Mortality
Did anybody in the household die in the past 12 months? If yes, fill up the details below.
Name/Relation Age at Date of Cause of death Did a health professional Check if the sick
demise Demise attend to the sick? If yes, who? was not attended by
a health
professional
1.✖️
Household 1 2.
3.
1.✖️
Household 2 2.
3.
1.✖️
Household 3 2.
3.
1.
Household 4 2.
3.
1.
Household 5 2.
3.

D. Use of medications
What are the medicines in your house today?
Name of What do you use it for? Who prescribed Name of medicine What do you use it for? Who prescribed
medicine it? it?
✖️

Household 1 Household 4
 MEFENAMIC OVARIAN CYST DOCTOR
AMOXICILLIN

Household 2 Household 5

✖️

Household 3

Do you use herbal medicines? If yes, fill up the table below.

Name of What do you use it for? Who prescribed Name of What do you use it for? Who prescribed
herb/plant it? herb/plant it?

✖️

Household 1 Household 4

✖️

Household 2 Household 5
 ✖️

Household 3

E. Nutrition
What did you eat yesterday?
R1 R2 R3 R4 R5
Breakfast FISH AND RICE FRIED CHICKEN, FRIED FISH AND RICE
EGGPLANT AND RICE

Snacks (AM) ✖️ BREAD COFFEE

Lunch HOTDOG AND RICE FRIED EGGPLANT AND EGG AND RICE
RICE

Snacks (PM) ✖️ BREAD COFFEE

Dinner BARBEQUE AND RICE CHICKEN AND FISH EGG, HOTDOG AND
AND RICE RICE

Others (specify)

F. Child Health: Child Health Services (for children under 5 years old)
Is a child regularly seen by a medical professional?
R1 R2 R3 R4 R5
Yes/No YES NO YES
If yes: HEALTH CENTER HEALTH CENTER
Health center/
Public hospital/
Private MD
 Fill up the following table for all children below 5 years of age in the household.
Name of Child Age Weight Height Nutritional Child services accessed within the last 6 mos
Months Years (kg) (cm) Status (see Feeding Deworming Vit. A Others
≤ 1 year > 1 year FNRI tables) (specify)
1.JASPER SERATO 1 mo 2.76KG BREASTFE
Household 1 ED
2.
3.
4.
5.
Name of Child Age Weight Height Nutritional Child services accessed within the last 6 mos
Months Years (kg) (cm) Status (see Feeding Deworming Vit. A Others
≤ 1 year > 1 year FNRI tables) (specify)
1. MADELINE 4yo SOLID NO
Household 2 FOOD
2.JAMIE LINE 4yo SOLID NO
FOOD
3.CADENCE 1yo 8kg MIXED NO
BREASFE
ED AND
SOLID
4.
5.
Name of Child Age Weight Height Nutritional Child services accessed within the last 6 mos
Months Years (kg) (cm) Status (see Feeding Deworming Vit. A Others
≤ 1 year > 1 year FNRI tables) (specify)
1.CASSANDRA ORCIA 11 mos 7.9KG MIXED NO NO
Household 3
2.NATALIE SECUYA 2yo SOLID NO NO
FOOD
3.
4.
5.
Name of Child Age Weight Height Nutritional Child services accessed within the last 6 mos
Months Years (kg) (cm) Status (see Feeding Deworming Vit. A Others
≤ 1 year > 1 year FNRI tables) (specify)
1.
Household 4 2.
3.
4.
5.
 Name of Child Age Weight Height Nutritional Child services accessed within the last 6 mos
Months Years (kg) (cm) Status (see Feeding Deworming Vit. A Others
≤ 1 year > 1 year FNRI tables) (specify)

1.
Household 5 2.
3.
4.
5.
Immunization: fill up the following table for each child.
Name of Child Source of vaccination With Health Card? Immunization received (refer to Health Card)
Health Govt Private Yes No BCG DPT OPV Measles HepB Others (Indicate)
center hospital MD 1 2 3 1 2 3
1.JASPER SERATO ✔️ ✔️
Household 1 2.
3.
4.
5.
Name of Child Source of vaccination With Health Card? Immunization received (refer to Health Card)
Health Govt Private Yes No BCG DPT OPV Measles HepB Others (Indicate)
center hospital MD 1 2 3 1 2 3
1.MADELINE ✔️ ✔️
Household 2 2.JAMIE LINE ✔️ ✔️
3.CADENCE ✔️ ✔️ ✔️
4.
5.
Name of Child Source of vaccination With Health Card? Immunization received (refer to Health Card)
Health Govt Private Yes No BCG DPT OPV Measles HepB Others (Indicate)
center hospital MD 1 2 3 1 2 3
1.CASSANDRA ORCIA ✔️ ✔️ ✔️ ✔️ ✔️ ✔️ ✔️ ✔️ ✔️ ✔️ ✔️
Household 3 2.NATALIE SECUYA ✔️ ✔️ ✔️ ✔️ ✔️ ✔️ ✔️ ✔️ ✔️ ✔️ ✔️
1.CASSANDRA ORCIA ✔️ ✔️ ✔️ ✔️ ✔️ ✔️ ✔️ ✔️ ✔️ ✔️ ✔️
4.
5.
Name of Child Source of vaccination With Health Card? Immunization received (refer to Health Card)
Health Govt Private Yes No BCG DPT OPV Measles HepB Others (Indicate)
center hospital MD 1 2 3 1 2 3
1.
Household 4 2.
3.
 4.
5.
Name of Child Source of vaccination With Health Card? Immunization received (refer to Health Card)
Health Govt Private Yes No BCG DPT OPV Measles HepB Others (Indicate)
center hospital MD 1 2 3 1 2 3
1.
Household 5 2.
3.
4.
5.

G. Maternal Health
For every woman in the household, fill up the table below.
Name of Woman OB Score Year Outcome Name of Woman OB Score Year Outcome
EVELYN SERATO 1001 G1 CS G1
JULIET SERATO 1001 G1 NSVD G2
ANGEL MAE SERATO 1001 G1 NSVD
1 4

Name of Woman OB Score Year Outcome Name of Woman OB Score Year Outcome
MADELINE CURAY 9008 G1 (1994) NSVD G1
G2 (1996)
G3 (1998)
G4 (2001)
2 G5 (2003) 5
G6 (2004)
G7 (2008)
G8 (2010)
G9 (2015)
JANNIE LINE 3003 G1 NSVD G2
G2
G3
STEPHANIE 0000 ✖️ ✖️
CHERRY 1001 G (2019) NSVD
 Name of Woman OB Score Year Outcome
WILSENE ORCIA 0000 ✖️ ✖️
WENDY ORCIA 0000 ✖️ ✖️
WELYN JANE ORCIA 1001 G1 NSVD
3
Pre- and Post-natal Care.
Fill up for all the women in the household who gave birth within the last 5 years. Fill the table below based on the last pregnancy of each of the women who gave birth in the
last 5 years.
When was your last baby delivered? JULY 2, 2020
What was the outcome of that last pregnancy? Term Preterm FDIU Aborted/miscarriage
Did you have prenatal care? Yes No
If yes, when did you have your first prenatal examination?  1st trimester 2nd trimester  3rd trimester
How many times did you receive prenatal care during this pregnancy? TWICE
How many doses of Tetanus Toxoid did you receive? 2
During this pregnancy, did you have any signs, symptoms or conditions that caused you to go to a health facility/professional health care provider right away?
Yes No
1 If yes, what were these symptoms or conditions?  Bleeding Dizziness Anemia Abdominal pain Others(Specify) CHEST PAIN AND SYNCOPE
Where did you deliver your child? Home Birthing home Hospital Others(Specify)
Who assisted you during the delivery? Hilot Midwife Doctor Others (Specify)
If at the hospital, how was the baby delivered? NSVD  Cesarian section Assisted (Specifiy)
After giving birth how many times did you visit a health facility/professional for check up (post natal care)? HEALTH CENTER
Yes  No Why not?
Did you breastfeed?
For how many months? 1
When was your last baby delivered? JANUARY 16, 2019
What was the outcome of that last pregnancy? Term Preterm FDIU Aborted/miscarriage
Did you have prenatal care? Yes No
If yes, when did you have your first prenatal examination? JULY 24, 2018 1st trimester  2nd trimester  3rd trimester
How many times did you receive prenatal care during this pregnancy? 7 TIMES
How many doses of Tetanus Toxoid did you receive? 1 DOSE
During this pregnancy, did you have any signs, symptoms or conditions that caused you to go to a health facility/professional health care provider right away?
Yes No
2 If yes, what were these symptoms or conditions?  Bleeding Dizziness Anemia Abdominal pain Others BACK PAIN
Where did you deliver your child? Home Birthing home Hospital Others(Specify)
Who assisted you during the delivery? Hilot Midwife Doctor Others (Specify)
 If at the hospital, how was the baby delivered? NSVD  Cesarian section Assisted (Specifiy)
After giving birth how many times did you visit a health facility/professional for check up (post natal care)? 8 TIMES
Yes For how many  No Why not?
Did you breastfeed?
months? 1 YEAR AND 6
MONTHS
When was your last baby delivered? AUGUST 18, 2019
What was the outcome of that last pregnancy? Term Preterm FDIU Aborted/miscarriage
Did you have prenatal care? Yes No
If yes, when did you have your first prenatal examination?  1st trimester 2nd trimester  3rd trimester
How many times did you receive prenatal care during this pregnancy? 5 TIMES
How many doses of Tetanus Toxoid did you receive? Unrecalled
During this pregnancy, did you have any signs, symptoms or conditions that caused you to go to a health facility/professional health care provider right away?
 Yes No
3 If yes, what were these symptoms or conditions?  Bleeding Dizziness Anemia Abdominal pain Others(Specify)
Where did you deliver your child? Home Birthing home Hospital Others(Specify)
Who assisted you during the delivery? Hilot Midwife Doctor Others (Specify)
If at the hospital, how was the baby delivered? NSVD  Cesarian section Assisted (Specifiy)
After giving birth how many times did you visit a health facility/professional for check up (post natal care)? NONE
Yes For how many  No Why not?
Did you breastfeed?
months? 11 MONTHS
When was your last baby delivered?
What was the outcome of that last pregnancy? Term Preterm FDIU Aborted/miscarriage
Did you have prenatal care? Yes No
If yes, when did you have your first prenatal examination?  1st trimester  2nd trimester  3rd trimester
How many times did you receive prenatal care during this pregnancy?
How many doses of Tetanus Toxoid did you receive?
During this pregnancy, did you have any signs, symptoms or conditions that caused you to go to a health facility/professional health care provider right away?
 Yes No
4 If yes, what were these symptoms or conditions?  Bleeding Dizziness Anemia Abdominal pain Others(Specify)
Where did you deliver your child? Home Birthing home Hospital Others(Specify)
Who assisted you during the delivery? Hilot Midwife Doctor Others (Specify)
If at the hospital, how was the baby delivered? NSVD  Cesarian section Assisted (Specifiy)
After giving birth how many times did you visit a health facility/professional for check up (post natal care)?
  Yes For how many  No Why not?
Did you breastfeed? months?
When was your last baby delivered?
What was the outcome of that last pregnancy? Term Preterm FDIU Aborted/miscarriage
Did you have prenatal care? Yes No
If yes, when did you have your first prenatal examination?  1st trimester  2nd trimester  3rd trimester
How many times did you receive prenatal care during this pregnancy?
How many doses of Tetanus Toxoid did you receive?
During this pregnancy, did you have any signs, symptoms or conditions that caused you to go to a health facility/professional health care provider right away?
 Yes No
5 If yes, what were these symptoms or conditions?  Bleeding Dizziness Anemia Abdominal pain Others(Specify)
Where did you deliver your child? Home Birthing home Hospital Others(Specify)
Who assisted you during the delivery? Hilot Midwife Doctor Others (Specify)
If at the hospital, how was the baby delivered? NSVD  Cesarian section Assisted (Specifiy)
After giving birth how many times did you visit a health facility/professional for check up (post natal care)?
 Yes For how many  No Why not?
Did you breastfeed?
months?

F. Family Planning Practice

Inquire each woman of reproductive age if she is menopausal or had undergone a hysterectomy. If yes, check the appropriate box and end the interview on FP. If she
answers no to both, proceed with the interview.  Menopausal  Had undergone hysterectomy
Are you currently pregnant?  No/unsure  Yes  end of FP interview
Do you want any more children?  No  Yes If yes, how many more?
Are you currently using any FP  No If no, why not?
method?  Yes If yes, check the method below.
Permanent Temporary
BTL V P IUD DMPA C LAM BBT Others (specify below)
1
Where did you get advice on your Private Public Others
current FP method?  Private Hospital Private Nurse/MW  Gov’t Hospital  Puericulture Center
 Pharmacy Industrial Based Clinic  RHCenter  Store
 Private Doctor NGO  BHS  Church
 Brgy Supply officer  Neighbor
 BHW
 Inquire each woman of reproductive age if she is menopausal or had undergone a hysterectomy. If yes, check the appropriate box and end the interview on FP. If she
answers no to both, proceed with the interview.  Menopausal  Had undergone hysterectomy
Are you currently pregnant?  No/unsure  Yes  end of FP interview
Do you want any more children?  No  Yes If yes, how many more?
Are you currently using any FP  No If no, why not?
method?  Yes If yes, check the method below.
Permanent Temporary
BTL V P IUD DMPA C LAM BBT Others (specify below)
2
Where did you get advice on your Private Public Others
current FP method?  Private Hospital Private Nurse/MW  Gov’t Hospital  Puericulture Center
 Pharmacy Industrial Based Clinic  RHCenter  Store
 Private Doctor NGO  BHS  Church
 Brgy Supply officer  Neighbor
 BHW
Inquire each woman of reproductive age if she is menopausal or had undergone a hysterectomy. If yes, check the appropriate box and end the interview on FP. If she
answers no to both, proceed with the interview.  Menopausal  Had undergone hysterectomy
Are you currently pregnant?  No/unsure  Yes  end of FP interview
Do you want any more children?  No  Yes If yes, how many more?
Are you currently using any FP  No If no, why not?
method?  Yes If yes, check the method below.
Permanent Temporary
BTL V P IUD DMPA C LAM BBT Others (specify below)
3
Where did you get advice on your Private Public Others
current FP method?  Private Hospital Private Nurse/MW  Gov’t Hospital  Puericulture Center
 Pharmacy Industrial Based Clinic  RHCenter  Store
 Private Doctor NGO  BHS  Church
 Brgy Supply officer  Neighbor
 BHW
Inquire each woman of reproductive age if she is menopausal or had undergone a hysterectomy. If yes, check the appropriate box and end the interview on FP. If she
answers no to both, proceed with the interview.  Menopausal  Had undergone hysterectomy
Are you currently pregnant?  No/unsure  Yes  end of FP interview
Do you want any more children?  No  Yes If yes, how many more?
Are you currently using any FP  No If no, why not?
method?  Yes If yes, check the method below.
Permanent Temporary
 BTL V P IUD DMPA C LAM BBT Others (specify below)
4
Where did you get advice on your Private Public Others
current FP method?  Private Hospital Private Nurse/MW  Gov’t Hospital  Puericulture Center
 Pharmacy Industrial Based Clinic  RHCenter  Store
 Private Doctor NGO  BHS  Church
 Brgy Supply officer  Neighbor
 BHW
Inquire each woman of reproductive age if she is menopausal or had undergone a hysterectomy. If yes, check the appropriate box and end the interview on FP. If she
answers no to both, proceed with the interview.  Menopausal  Had undergone hysterectomy
Are you currently pregnant?  No/unsure  Yes  end of FP interview
Do you want any more children?  No  Yes If yes, how many more?
Are you currently using any FP  No If no, why not?
method?  Yes If yes, check the method below.
Permanent Temporary
BTL V P IUD DMPA C LAM BBT Others (specify below)
5
Where did you get advice on your Private Public Others
current FP method?  Private Hospital Private Nurse/MW  Gov’t Hospital  Puericulture Center
 Pharmacy Industrial Based Clinic  RHCenter  Store
 Private Doctor NGO  BHS  Church
 Brgy Supply officer  Neighbor
 BHW
RESPONDENT 1: JULIET SERATO

REPRODUCTIVE PROFILE QUESTIONNAIRE by Group F-Talikala

I. OBSTETRIC HISTORY
a. What age were you when you first gave birth? 17
b. Was this pregnancy planned? NO
c. Was the pregnancy the result of a sexual encounter that was: wanted, unwanted? UNWANTED
d. How did you find out you were pregnant? PT
e. What was your reaction to finding out you were pregnant? KULBAAN
f. What were the reactions of your family, friends, neighbors, teachers, etc? FATHER SUKO, THE REST DAWAT NILA
g. Did your family and/or partner support you during this time? SUPPORTED
h. Did you experience any kind of discrimination from other people because you were a teenage mother? YES SA DOCTOR AND TAO DILI KAILA
i. Did you consider abortion? NO
j. Did you have regular prenatal checkups? YES
k. Describe each pregnancy – complications and outcomes NO CPMPLICATIONS
II. GYNECOLOGIC HISTORY
a. Age at menarche 12
b. Do you have your period regularly? Duration, heaviness of flow, associated pain REGULAR, 3-7 DAYS, MODERATE FLOW, NONE
c. Did you have gynecologic checkups before getting pregnant? NONE
d. At what age did you first have sex? 15
e. Who/what influenced you to have sex at that age? BOYFRIEND
f. Did you have prior knowledge about sex? And if yes, from who or what? YES, SOCIAL MEDIA AND TALIKALA
g. Do you know other teenage mothers personally? YES (CLASSMATES)
III. VAWC
a. Has anyone ever physically or verbally abused you? Whether your partner or a family member. YES partner physical and verbal; family member father verbal
b. Have you ever been made to do sexual favors against your will? Yes but di gidawat
c. Have you ever been discriminated against by a health professional or institution? Doctor spmc
IV. FAMILY PLANNING HISTORY
a. Did you know about family planning and birth control at the time you first got pregnant? Yes condom and pills
b. Did/Do you and your partner use any method of birth control? And if yes, what, and are you satisfied with the method? no
c. Did/Do you have difficulty in attaining birth control? no
d. Do you plan to have more children? yes
V. MENTAL HEALTH HISTORY
a. Do you have any history of depression? NO
b. Did you ever think of committing suicide when you became pregnant? NO
VI. OTHERS
a. How would you describe your sexual orientation? STRAIGHT
b. Do you know sex workers personally? Have you ever thought of becoming one yourself? Wala, WALA
c. How do you feel towards sex work? Dili siya dapat buhaton dapat dili mag trabaho na dali na trabaho na gamit na lawas
 d. Were you living with a parent/guardian when you got pregnant? yes
e. Were you in school at the time? YES
f. What is the highest level of schooling you completed? Grade 11
g. Are you currently regular school, college, university? Full time or part time? ENROLLED
h. Did you have to stop your schooling because of the pregnancy? Would you want to go back? YES and yes
i. Did you regret becoming pregnant at a very young age? NO
j. Access to health facilities and medicine during CQ: YES
k. Access to food and child needs during CQ: yes
l. Access to birth control during CQ: yes
m. Source of income during CQ: yes
n. Other difficulties related to pregnancy (if currently pregnant) and child-rearing during pandemic
o. What do you think should be done so that there can be a better RH response in the city?
Spmc ilahi ang covid. Pde naa pud pa check up sa non cobid check ups kay mahal man gud sa mga private.

RESPONDENT 2: CHERRY CURAY

REPRODUCTIVE PROFILE QUESTIONNAIRE by Group F-Talikala

VII. OBSTETRIC HISTORY
l. What age were you when you first gave birth? 15
m. Was this pregnancy planned? NO
n. Was the pregnancy the result of a sexual encounter that was: wanted, unwanted? UNWANTED
o. How did you find out you were pregnant? PT
p. What was your reaction to finding out you were pregnant? KULBAAN
q. What were the reactions of your family, friends, neighbors, teachers, etc? ACCEPTED
r. Did your family and/or partner support you during this time? SUPPORTED
s. Did you experience any kind of discrimination from other people because you were a teenage mother? YES NEIGHBORS
t. Did you consider abortion? NO
u. Did you have regular prenatal checkups? NO
v. Describe each pregnancy – complications and outcomes DIFFICULTY OF BREATHING 4 MONTHS, NERVOUS ABOUT PREGNANCY
VIII. GYNECOLOGIC HISTORY
h. Age at menarche 14
i. Do you have your period regularly? Duration, heaviness of flow, associated pain IREGULAR, 5-DAYS, HEAVY FLOW, DYSMENORRHEA
j. Did you have gynecologic checkups before getting pregnant? NONE
k. At what age did you first have sex? 13
l. Who/what influenced you to have sex at that age? BOYFRIEND
m. Did you have prior knowledge about sex? And if yes, from who or what? YES THRU FRIENDS
n. Do you know other teenage mothers personally? YES (FRIENDS)
IX. VAWC
d. Has anyone ever physically or verbally abused you? Whether your partner or a family member. YES NEIGHBOR physical
e. Have you ever been made to do sexual favors against your will? NO
 f. Have you ever been discriminated against by a health professional or institution? NO
X. FAMILY PLANNING HISTORY
e. Did you know about family planning and birth control at the time you first got pregnant? Yes condom and pills
f. Did/Do you and your partner use any method of birth control? And if yes, what, and are you satisfied with the method? no
g. Did/Do you have difficulty in attaining birth control? no
h. Do you plan to have more children? yes
XI. MENTAL HEALTH HISTORY
c. Do you have any history of depression? no
d. Did you ever think of committing suicide when you became pregnant? no
XII. OTHERS
p. How would you describe your sexual orientation? BISEXUAL
q. Do you know sex workers personally? Have you ever thought of becoming one yourself? Wala, dili wala never
r. How do you feel towards sex work? SCARED ABOUT THE NATURE OF WORK
s. Were you living with a parent/guardian when you got pregnant? yes
t. Were you in school at the time? no
u. What is the highest level of schooling you completed? Grade 8
v. Are you currently regular school, college, university? Full time or part time? NO
w. Did you have to stop your schooling because of the pregnancy? Would you want to go back? NO and yes
x. Did you regret becoming pregnant at a very young age? YES
y. Access to health facilities and medicine during CQ: yes
z. Access to food and child needs during CQ: yes
a. Access to birth control during CQ: yes
b. Source of income during CQ: yes
c. Other difficulties related to pregnancy (if currently pregnant) and child-rearing during pandemic
d. What do you think should be done so that there can be a better RH response in the city?
e. FREE PILLS AND FAMILY PLANNING

RESPONDENT 3: WELYN JANE ORCIA

REPRODUCTIVE PROFILE QUESTIONNAIRE by Group F-Talikala

XIII. OBSTETRIC HISTORY
w. What age were you when you first gave birth? 15
x. Was this pregnancy planned? NO
y. Was the pregnancy the result of a sexual encounter that was: wanted, unwanted? UNWANTED
z. How did you find out you were pregnant? PT
a. What was your reaction to finding out you were pregnant? KULBAAN
b. What were the reactions of your family, friends, neighbors, teachers, etc? SHOCKED
c. Did your family and/or partner support you during this time? SUPPORTED
d. Did you experience any kind of discrimination from other people because you were a teenage mother? YES
e. Did you consider abortion? NO
 f. Did you have regular prenatal checkups? YES
g. Describe each pregnancy – complications and outcomes NO CPMPLICATIONS
XIV. GYNECOLOGIC HISTORY
o. Age at menarche 12
p. Do you have your period regularly? Duration, heaviness of flow, associated pain IREGULAR, 7 DAYS, MODERATE FLOW, NONE
q. Did you have gynecologic checkups before getting pregnant? NONE
r. At what age did you first have sex? 15
s. Who/what influenced you to have sex at that age? HERSELF
t. Did you have prior knowledge about sex? And if yes, from who or what? YES, BOYFRIEND
u. Do you know other teenage mothers personally? YES (FRIENDS)
XV. VAWC
g. Has anyone ever physically or verbally abused you? Whether your partner or a family member? NO
h. Have you ever been made to do sexual favors against your will? Yes
i. Have you ever been discriminated against by a health professional or institution? NO
XVI. FAMILY PLANNING HISTORY
i. Did you know about family planning and birth control at the time you first got pregnant? NO
j. Did/Do you and your partner use any method of birth control? And if yes, what, and are you satisfied with the method? no
k. Did/Do you have difficulty in attaining birth control? YES
l. Do you plan to have more children? NO
XVII. MENTAL HEALTH HISTORY
e. Do you have any history of depression? NO
f. Did you ever think of committing suicide when you became pregnant? NO
XVIII. OTHERS
a. How would you describe your sexual orientation? STRAIGHT
b. Do you know sex workers personally? Have you ever thought of becoming one yourself? Wala, WALA
c. How do you feel towards sex work? DIRTY WORK
d. Were you living with a parent/guardian when you got pregnant? yes
e. Were you in school at the time? YES
f. What is the highest level of schooling you completed? Grade 6
g. Are you currently regular school, college, university? Full time or part time? NO
h. Did you have to stop your schooling because of the pregnancy? Would you want to go back? NO and yes
i. Did you regret becoming pregnant at a very young age? YES
j. Access to health facilities and medicine during CQ: YES
k. Access to food and child needs during CQ: yes
l. Access to birth control during CQ: yes
m. Source of income during CQ: yes
n. Other difficulties related to pregnancy (if currently pregnant) and child-rearing during pandemic
o. What do you think should be done so that there can be a better RH response in the city?
a. NONE THANKFUL LANG SA HC
RESPONDENT 4: ALICE CABALO

REPRODUCTIVE PROFILE QUESTIONNAIRE by Group F-Talikala

XIX. OBSTETRIC HISTORY
a. What age were you when you first gave birth?
b. Was this pregnancy planned?
c. Was the pregnancy the result of a sexual encounter that was: wanted, unwanted?
d. How did you find out you were pregnant?
e. What was your reaction to finding out you were pregnant?
f. What were the reactions of your family, friends, neighbors, teachers, etc?
g. Did your family and/or partner support you during this time?
h. Did you experience any kind of discrimination from other people because you were a teenage mother?
i. Did you consider abortion?
j. Did you have regular prenatal checkups?
k. Describe each pregnancy – complications and outcomes
l. Do you have your period regularly?
m. Did you have gynecologic checkups before getting pregnant?
n. At what age did you first have sex?
o. Who/what influenced you to have sex at that age?
p. Did you have prior knowledge about sex? And if yes, from who or what?
q. Do you know other teenage mothers personally?
XX. VAWC
j. Has anyone ever physically or verbally abused you? Whether your partner or a family member.
k. Have you ever been made to do sexual favors against your will?
l. Have you ever been discriminated against by a health professional or institution?
XXI. FAMILY PLANNING HISTORY
m. Did you know about family planning and birth control at the time you first got pregnant?
n. Did/Do you and your partner use any method of birth control? And if yes, what, and are you satisfied with the method? no
o. Did/Do you have difficulty in attaining birth control?
p. Do you plan to have more children?
XXII. MENTAL HEALTH HISTORY
g. Do you have any history of depression?
h. Did you ever think of committing suicide when you became pregnant?
XXIII. OTHERS
aa. How would you describe your sexual orientation?
a. Do you know sex workers personally? Have you ever thought of becoming one yourself?
b. How do you feel towards sex work?
c. Were you living with a parent/guardian when you got pregnant?
d. Were you in school at the time?
e. What is the highest level of schooling you completed?
f. Are you currently regular school, college, university? Full time or part time?
g. Did you have to stop your schooling because of the pregnancy? Would you want to go back?
h. Did you regret becoming pregnant at a very young age?
i. Access to health facilities and medicine during CQ:
j. Access to food and child needs during CQ:
k. Access to birth control during CQ:
l. Source of income during CQ:
m. Other difficulties related to pregnancy (if currently pregnant) and child-rearing during pandemic
n. What do you think should be done so that there can be a better RH response in the city?
o. FREE PILLS AND FAMILY PLANNING