HOUSEHOLD PROFILING FORM

Date of Visit (mm/dd/yyyy)

Municipality/City/District: __________________________ Interviewed by: __________________________________ First Quarter:

Second Quarter:
Third Quarter:
Province: _______________________________________ Reviewed by: ____________________________________ Fourth Quarter:

Household Information Name of Respondent Ethnicity (Please Tick) Socioeconomic Status (Please Tick) Environmental Health Data

Sitio/Purok: Last Name:

⃝ IP Household ⃝ NHTS 4Ps Type of Water Source: Type of Toilet Facility:
If IP Household, indicate Tribe:
Barangay: First Name: ⃝ NHTS Non-4Ps select from the following: select from the following:
Level I - Point Source
⃝ Non-NHTS
Level II - Communal Faucet Level III - Individual A - Pour/flush type connected to septic tank E - Overhung latrine
Household (HH) Number: Middle Name: Connection
If NHTS, please indicate the NHTS No.:
B - Pour/flush toilet connected to septic tank AND to sewerage system F - Open pit latrine
Others - For doubtful sources, open dug well etc. C - Ventilated Pit (VIP) latrine D - Water-sealed toilet G - Without toilet
Relationship to HH Head:
⃝ Non-IP Household *write the type of water source in the box provided above *write the type of toilet facility in the box provided above

Relation
-ship of Philhealth ID Member Philhealth Last Mestrual Educational
Name of Household Members Sex Date of Birth Civil Status Medical History Women of Reproductive Age (WRA) Classification by Age/Health Risk Group Religion Remarks
members to HH Number -ship Type Category Period (LMP) Attainment
Head
1 - Head M- Write the birthday M - Married M - Member FEP - Formal HPN - Write the LMP in N - None Example: Write additional notes
2 - Spouse Male in this date format: S - Single D - Dependent Economy Private Hypertension DM - this date format: Using any FP Family Planning N-Newborn P-Pregnant K - Kinder Roman Catholic, such occupation,
FP Status ES -Elem Student EU - Christian, INC, nutritional status, or
3 - Son F- mm/dd/yyyy W - Widow/er FEG - Formal Diabetes TB - mm/dd/yyyy method? Method used AB- Adult >25 y.o AP- Adolecent Pregnant
Elem Undergrad EG - Catholic, Islam, any other detail
4 - Daughter Female SP - Economy Tuberculosis SC - Senior Citizen PP-Postpartum Elem Graduate HS - HS Baptist, Born Again, related to each
5 - Others, Separated Government S - Surgery Y - Yes Choose from the NA - New Acceptor WRA - Women with Rep Age I-Infnat Student Christian, Buddhism, member of the
(Please provide the names of the members of the household
specify relation C- IE - Informal N - No following: COC, CU - Current User S- School Age (0-5 y.o.) U-under 5 y.o. HU - HS Undergrad Church of God, household
starting from the household head followed by spouse, HG - HS Graduate Jehovahs Witness,
Cohabitation Economy POP, CM - Changing A-Adolecent (10-19 y.o.) PWD -person with disability
son/daughter (eldest to youngest), and other members V - Vocational Course Protestant, Seventh
N - NHTS Injectables, IUD, Method
CS - College Student Day Adventist, LDS-
SC - Senior Condom, LAM, CC - Changing CU - College Undergrad Mormons,
Citizen BTL, Implant, Clinic CG - College Graduate Envangelical,
1st Quarter 2nd Quarter 3rd Quarter 4th Quarter
IP - Indigenous SDM, DPT, DO - Dropout PG - Postgraduate Pentecostal,
People Withdrawal, R - Restarter Unknown, Other
U - Unknown Others
Last Name First Name Middle Name Age Class Age Class Age Class Age Class