FAMILY # Name of Household Members Relationship to the Head of the Family (ALL)

H-Head W-Wife S-Son D-Daughter SB-

FAMILY # Name of Household Members
Sibling Others:

1 1 FALCULAN, EMIL HEAD

2 1 GERALDEZ, ELMARIE WIFE

3 1 FALCULAN, EDRIEL SON

25 6 CERERA, ERICSON HEAD

26 6 CERERA, KHAREN WIFE

27 6 CERERA, EIRISHEN KISHA DAUGHTER

28 7 ARCE, LUISITO HEAD

29 7 DEDIOS, MARY EDEN WIFE

30 7 ARCE, PRECIOUS NICOLE DAUGHTER

31 7 DEDIOS, LAURIANA MOTHER

32 8 BUENVENIDA, GINALYN WIFE

33 8 JOBINA, JOHN HEAD

34 8 RAMIREZ, MOISES SON

35 9 BORROMEO, LOWEL HEAD

36 9 BORROMEO, PATRIA MOTHER

37 9 BORROMEO, ANTHONY JEROME SON

38 9 BORROMEO, JOHN LOWEL SON

39 9 BORROMEO, IVAN RYAN SON

40 9 BORROMEO, KIM JOEY SON

41 10 BELLA, HILDA WIFE

42 10 BELLA, POLICARPIO HEAD

43 10 BELLA, JESSICA DAUGHTER IN LAW

44 10 BELLA, PATRICK SON

45 10 BELLA, HAZEL DAUGHTER

46 10 BELLA, ANSHERINA DAUGHTER

47 10 BELLA, DOMINGO HEAD

48 10 BELLA, TRIXIE MADISON GRAND DAUGHTER

49 16 GARCIA, FERNANDO HEAD

50 16 GARCIA, REMEDIOS MOTHER

51 16 SIENES, RINA LYKA NIECE

52 17 SORIANO, NARCISO HEAD

53 17 SORIANO, NERISA

54 17 SORIANO, NIKKA DAUGHTER

55 17 SORIANO, CATHELENE MAE DAUGHTER

56 18 PERHIS, JOHN PERSIBAL HEAD

57 18 PERHIS, ANALICE WIFE

58 18 PERHIS, AIJ SON

59 18 PERHIS, HANNAH JEAN DAUGHTER

60 18 PERHIS, JOANA DAUGHTER

61 19 YABUT, RIZALINO HEAD

62 19 YABUT, PINEDA MOTHER

63 19 YABUT, RHIMA NICOLE DAUGHTER

64 19 YABUT, JANE WIFE

65 19 YABUT, RHENZ JADEN SON

66 20 KABAGANI, LOVELY ADAM HEAD

67 20 KABAGANI, MATIT SISTER

68 20 KABAGANI, ANIEZA MOTHER

69 20 KABAGANI, FAIHAYNIE NIECE

70 20 KABAGANI, AALIFA NIECE

71 21 LACANARIA, RAUL HEAD

72 21 LACANARIA, MARILYN MOTHER

73 21 LACANARIA, ANGEL DAUGHTER

74 21 LACANARIA, NINO SON

75 21 LACANARIA, HEAVEN DAUGHTER

76 22 BATTUNG, MILAGROS MOTHER

77 22 BASSONG, RICHARD HEAD

78 22 BASSONG, JOHNRICK SON

79 23 FINE, JERRY HEAD

80 23 LOMPOT, CHERRY MOTHER

81 23 FINE, CHERRY DAUGHTER

82 24 GARCIA, REYNALDO HEAD

83 24 GARCIA, RODA MOTHER

84 24 GARCIA, ENYA DAUGHTER

85 24 GARCIA, ALTHEA DAUGHTER

86 25 SENA, EJERCITO HEAD

87 25 CLEMENTE, JAYMIE MOTHER

88 25 CLEMENTE, JHUENES DAUGHTER

89 25 CLEMENTE, JHUDEL SON

90 25 SENA, PRINCESS DAUGHTER

91 26 YABUT, PENNY W

92 26 YABUT, RHIMA * GRAND DAUGHTER

93 27 NALHERDY V. CORTEZ PADER H

94 28 LOUISA PADER W

95 29 MAVI PADER S

95 30

CHRISTINE RICAFORT H

95 30

ATHENA RICAFORT

95 30

MARTIN DELIMA

95 31

STEPHANIE RICAFORT H

100 31

BRITS YRA
101 31

KIARA YRA

32

102 MARYRM OTHERS

33

103 MEL BERT PARAFIIRA H

33

104 MARIAL PARAFIRA W

33

105 MARIA KATRINA PARAFIRA

34
106 JOHN HENDRIX

35
107 IVAN MIGUEL

36
108 MEL BERT JR.

109 37 ANALISA ALACIO H

110 38 MELCHOR ARCILIA

111 38 KIM PRANKSON

112 38 LANCE HENRY

113 38 MELISA
AGE (ALL) SEX (ALL) RELIGION (ALL) CIVIL STATUS (21 y/o and above)

RC-Roman Catholic I-Inglesia ni Kristo P-

M-Male F-Female Protestant SA-Seventh Day Adventist JW- S-Single M-Married
Jehovas Witness Others:

33 M RC CL

31 F RC CL

1.58 M RC S

36 M RC M

35 F RC M

13 F RC

44 M RC CL

41 F RC CL

12 F RC

82 F RC W

30 F BORN AGAIN CL

47 M BORN AGAIN CL

12 M BORN AGAIN
51 M RC M

52 F RC M

26 M RC S

25 M RC S

23 M RC S

18 M RC

49 F RC M

49 M RC M

23 F CHISTIAN M

26 M RC M

23 F RC S

18 F RC

93 M RC M

3 F RC

45 M RC M

73 F RC W
11 F RC

67 F PLORORITA M

50 F PLORORITA CL

18 F PLORORITA

17 F PLORORITA

47 M RC M

46 F RC M

17 M RC

14 F RC

11 F RC

35 M RC M

66 F P W

10 F RC

27 F RC M

4 M RC

39 F ISLAM S

32 F ISLAM S
60 F ISLAM W

6 F ISLAM

0.1 F ISLAM

47 M RC M

46 F RC M

18 F RC

17 M RC

7 F RC

43 F RC CL

37 M RC CL

7 M RC

27 M RC CL

27 F RC CL

4 F RC

39 M RC M

37 F RC M

13 F RC
12 F RC

34 M RC CL

37 F RC CL

12 F RC

11 M RC

6 F RC

69 F CHRISTIAN M

12 F CHRISTIAN

43 M CHRISTIAN M

42 F CHRISTIAN M

18 M CHRISTIAN

31 F I

11 F I

28 M RC

28 F RC

29 M RC
4 F RC

28 RC

42 M RC M

43 F RC M

19 F RC

16 M RC

10 M RC

21 M RC

37 F RC

41 M RC

14 F RC

13 M RC

9 F RC
 HIGHEST EDUC. ATTAIN. (21 y/o and above) TYPE OF WORK (21 y/o & above) FAMILY STRUCTURE DOMINANCE

CG-College Graduate CU-College

Undergraduate HS-High Sch. Graduate HU-
High Sch. Undergraduate EG - Elementary N-Nuclear SP-Single Parent C-Cohabiting B-
W-White Collar Job B-Blue Collar Job P-Patriarchal M- Matriarchal E-Equalitarian
Graduate EU - Elementary Undergraduate Blended E-Extended Others:
VG - Vocational Graduate VU - Vocational
Undergraduate NFE - No Formal Education

CG W N P

CG W

CG W N E

CG NONE

CU B E P

HG NONE

CU NONE

HG NONE N E

HG B
CU B N P

EG

CG W

CG W

CG W

CG W E E

HG

HU

CG W

CG

EG

CG W N P

HG
CU B C P

CU

CG W N P

CG

CU EM N P

EU

HU

CG T SP M

CG
EU

EM B N E

UM

UM

EM W C P

EM W C P

UM

EM W N E

UM
 HU EM C E

CG UM

EG BC SP M

CU N P

CG N

CU B C M

CU B C M

CU B C M

CU B N P
HS OTHERS

CU B N P

HS B N M

HS N

CU N
# OF SPOUSE RESIDENCE DIALECT USE SOURCES OF HEALTH INFO.

T-Tagalog I-Ilocano BC-Bicolano BS-Bisaya

P-Patrilocal M-Matrilocal N-Neolocal N-Neighbors B-Barangay HC-Health Center
Others, specify ___________

M N TAGALOG SOCIAL MEDIA

M N TAGALOG, BICOLANO, ILONGGO NEIGHBOR

P N TAGALOG, BICOLANO, BISAYA NEIGHBOR

M N TAGALOG, BICOLANO NONE

M N TAGALOG NEIGHBOR

M M TAGALOG
P P TAGALOG NEIGHBOR

M P TAGALOG NEIGHBOR

M M TAGALOG NEIGHBOR

M TAGALOG NEIGHBOR
M N TAGALOG N

N TAGALOG N

M TAGALOG N

M P TAGALOG N
 N TAGALOG N

M T HC

T HC

M BS PH

OTHERS (CEB) PH

T PH

M BS,T, OTHERS N

M T, OTHERS N OV

P M N T, J

T, BS T
P T M

M T F

T F

T M

T M

T M

T, BC

T, BC

T
 MEANS OF TRANSPO. KIND OF NEIGHBOR- HOOD HOME LAND

T-Tricycle P-Pedicab J-Jeepney M- O-Owned LO-Leased to Own R-Rented RF- O-Owned LO-Leased to Own R-Rented RF-
C-Congested U-Uncongested
Motorcycle OV-Own Vehicle Rent Free Rent Free

TRI O O

TRI C O LO

TRI C O LO
TRI C O O

TRI C O O

TRIC O O
TRIC O O

TRIC O O

TRIC O O

TRIC O O
TRIC O RF

TRIC C O O

TRIC C O O

TRIC C O RF
 TRIC C R R

TRIC C O O

T C O O

M C O O

M C O O

M C O O

T, LRT C O O

C O O O

C RF O O

R R
HC T C O

HC T C O

HC T, J O

HC T O

HC T C O

HC T C O

N T C R
 OTHER INCOME AVE. MONTHLY INCOME PRIORITIES SOURCES OF FUND RE: HEALTH

Below 5,000 5,000-10,000

10,001-15,000
SS-Sari-sari Store BS-Buy and Sell L- F-Food H-Health S-Shelter E-Education
15,001-20,000 S-Savings HC-Health Card L-Loan
Lending V-Vlogging Others: __________ Others:___________
20,001-25,000
25,001-30,000 30,001 and above

PRINTING, COM.SHOP 10,001-15,000 EDUCATION SAVINGS

SELLING SOAP, BREEDING DOGS,

TRICYCLE SERVICE, CONSTRUCTION 5,000-10,000 FOOD SAVINGS
WORK

5,000-10,000 FOOD SAVINGS

 10,001-15,000 HEALTH SAVINGS

GARMENTS BUSINESS 5,000-10,000 FOOD SAVINGS

20,001-25,OOO HEALTH SAVINGS

SST 10,001-15,000 FOOD HEALTH SAVINGS

N 5,000,10,000 FOOD SAVINGS

SST 35,001-40,000 HEALTH SAVINGS

SST 30,001-35,OOO HEALTH SAVINGS

SST 5000-10000 H S

50,001-ABOVE F S

HC 40,001-45,000 H S

SST 20,001-25,000 F S
 10,001-15,000 F S

1K F HC

HC

OTHERS 22K F,H,S HC

S 26K E S

O 10K - 16K S,F,H,E S

OTHERS 10K - 16K S,F,H,E S

OTHERS 10K - 16K S,F,H,E S

F,H,E,S S
O

O IHAW-IHAW 10K - 15K F,E,H,S

R OTHERS 25K - 30K F,H,S,E

 MATERIALS USED IN HOUSING NO. OF ROOMS INSIDE THE HOUSE Number of people sleeping in one (1) room Number of windows in the house

W-Wood C-Concrete M-Mixed

STRONG

STRONG

STRONG ADEQ
STRONG ADEQ

STRONG ADEQ

STRONG
MIXED

MIXED

MIXED

STRONG
S ADEQ

S ADEQ

M ADEQ

S ADEQ
 M ADEQ

M 1 2 1

M 1 2 1

M 3 1 5

M 3 1 5

M 3 1 5

M 3 3 3

M 3 3 3

M 3 3 3

M 2 1 3
 M 3 2

S M 3 2

M 3 2

M 3 2

M 3 2

L M 2 5
 LIGHTNING FACILITIES LIGHTNING ADEQUATE? VENTILATION ADEQUATE? SOURCES OF HOUSEHOLD WATER

E-Electricity K-Kerosene C-Candle C-Commercial W-Wells R-River

YES NO YES NO
Others:______ Others:______

E Y Y COM WATER

E Y Y COM WATER

E Y Y COM WATER
E Y Y COM WATER

E Y Y COM WATER

E Y Y COM WATER
E Y Y COM WATER

E Y Y COM WTER

E Y Y COM WATER

E Y Y COM WATER
E Y Y CW

E Y Y CW

E Y Y CW

E Y Y CW
 E Y Y CW

E NO YES C

E NO YES C

E YES YES C

E YES YES C

E YES YES C

E YES YES C

E YES YES C

E YES YES C

E
2 E YES YES

2 E YES YES

2 E YES YES

2 E YES YES

2 E YES YES

2
 HOUSEHOLD WATER STORAGE SOURCEOF DRIKING WATER DRINKING WATER STORAGE TOILET

C-Covered U-Uncovered N-None C-Commercial B-Boiled P-Potable Water C-Covered U-Uncovered N-None O-Owned P-Public S-Share

C COM WATER C O

C COM WATER C O

C COM WATER C O
C COM WATER C O

C COM WATER C O

N LOC WATER C O
N COM WATER C O

N COM WATER C 0

C COM WATER C O

C COM WATER U O
N CW C O

C CW C O

N CW C O

N CW C O
 N CW C O

C C C O

C C C O

C C C O

C C C O

C C C S

C C C O

C C C O

C C C O

O
C C C C

C C C C

C C C C

C C C C

C C C C

C C C C
 DISTANCE OF TOILET FROM DRINKING WATER
TYPE OF TOILET TYPE OF DRAINAGE S-Stagnant F-Free Flowing
SOUCE

P-Pale System F-Flush Type Others:

25 METERS & UP 24 METERS & BELOW O-Open C-Closed N-None S-Stagnant F-Free Flowing
___________

F O FREE FLOWING

P B FREE FLOWING

P B FREE FLOWING
F B FREE FLOWING

F B FREE FLOWING

P B FREE FLOWING
F O FREE FLOWING

F O FREE FLOWING

P B FREE FLOWING

P B FREE FLOWING
P N

F N

P N

F O FREE FLOWING
 P

P 2M C S

P 2M C S

P 1M C S

P 1M C S

P 1M C S

P 24M

P 25M

P 25M

P 25M
O P 3M O

O P 3M O

O P 3M O

O P 3M O

O P 3M O

O P 24M BELOW O
 METHOD OF GARBAGE DISPOSAL FOOD PREP FOOD STORAGE DOMESTIC ANIMALS

F-Fried
C-Collected OD-Open dumping
S-Steamed G-Grilled C-Covered U-Uncovered R-Regfrigerated C-Cat D-Dog C-Chicken D-Ducks Others:
OB-Open burning C-Composting B-Burying
B-Boiled

GARBAGE COLLECTION FRIED STEAMEDGRILLED BOILED C DOG

GARBAGE COLLECTION FRIED STEAMEDGRILLED BOILED C DOG

GARBAGE COLLECTION FRIED STEAMEDGRILLED BOILED C DOG, CAT

GARBAGE COLLECTION FRIED STEAMEDGRILLED BOILED C NONE

GARBAGE COLLECTION FRIED STEAMEDGRILLED BOILED C NONE

G FRIED C NONE
G NILAGA FRIED C NONE

G FRIED C NONE

G FRIED C NONE

G FRIED BOILED C DOG

G F C CAT

G F C

G B C DOG

G B C DOG
 G F C

C B

C B R

C F C C,D,F

C F C C,D,F

C F C

OB F,S,G,B R

OB F,S,G,B R

B R C,D
F C R D

F C R D

F C R D

F C R D

F C R D

B C C D,C
 VECTORS PRESENT IN THE HOUSE METHODS OF VECTORS CONTROL COMMON ILLNESSES CAUSES OF ILLNESSES

F-Flies R-Rats I-Insecticides T-Traps F-Fever C-Cough S-Supernatural cause HR-Health related
C-Cockroaches M-Mosquitos T-Termites F-Fumigation GS-Good Sanitation N-None F-Flu Others: causes

RATS COCKROACHES FLIES MOSQUITO HEALTH RELATED CAUSES,

INSECTISIDES, GOOD SANITATION COUGH FLU
TERMITES SUPERNATURAL CAUSE

HEALTH RELATED CAUSES,

RATS COCKROACHES FLIES MOSQUITO NONE FEVER, COUGH FLU
SUPERNATURAL CAUSE

COCKROACHES FLIES MOSQUITO NONE COUGH FLU HEALTH RELATED CAUSES

COCKROACHES FLIES MOSQUITO INSECTISIDES, GOOD SANITATION COUGH FLU HEALTH RELATED CAUSES

COCKROACHES FLIES MOSQUITO INSECTISIDES, GOOD SANITATION COUGH FLU HEALTH RELATED CAUSES

MOSQUITO USE OF INSECTICIDES FEVER HEALTH RELATED CAUSES

 MOSQUITO USE OF INSECTICIDES FEVER HEALTH RELATED CAUSES

COCKROACHED MOSQUITO USE OF INSECTICIDES FEVER HEALTH RELATED CAUSES

MOSQUITO USE OF INSECTICIDES FEVER HEALTH RELATED

MOSQUITO FLIES USE OF INSECTICIDES FEVER COUGH HEALTH RELATED

F UI FEVER HR

F UI FEVER HR

M UI FEVER HR

C GS FEVER HR
 M F FEVER HR

F,R,C,M,T I,T HB HR

F,R,C,M,T I,T

F,R,C,M I,T

C,M,R,F I, GS F,C S

C,M,R,F I, GS F,C S

F,C,M I F S
C,M,R I F,C

C,M,R I F,C

M,R I F,C

M,R I F,C

M,R I F,C

F,C

M I C,F
 CONSULT DURING ILLNESSES MEDICATIONS COMMUNITY PROGRAMS UTILIZED FAM. PLANNING METHOD

R-Rhythm method
A-Abstinence
P-Pills
D-Doctors N-Nurses M-Midwife P-Prescribed by M.D. SM-Self-medication G-General check-up HTP-Health Teaching
C-Condoms
H-Hilot A-Albularyo FH-Faith healers HM-Herbal Meds. N-None Programs
TL-Tubal Ligation
V-Vasectomy
Others:

DOCTORS RX, HM GEN NONE

HILOT DOCTORS NURSES RX, HM NONE NONE

DOCTORS RX, HM GEN NONE

DOCTORS RX GEN NONE

DOCTORS RX, HM NONE

DOCTORS RX, HM NONE

DOCTORS M.D NONE

DOCTORS M.D GEN

NURSES SM GEN

DOCTOR HM GEN

DOCTOR MD GEN
DR MD Y

DR MD Y

DR OTC Y

DR MD Y
 MW HM Y

D P P

D P

D P G R

D P R

D P

D HM G

D HM G

D
D P

D P

D P

D P

D P

N,D P HTP
HEIGHT (0-7 y/o) WEIGHT (0-7 y/o) GEN. NUTRITIONAL STATUS (BMI) (0-7 Y/O) IMMU- NIZATION (1-8 Y/O)

BCG DPT OPV HEPA B MMR

3 FT 15 KG

84 CM 23.9 10.86 C

120 CM 66 30 C

74 CM 18.9 8.59 C

-
-

-
 -

2FT 6 KG

-
 -

4FT 8KG

4FT - INC

INC

4FT 46.2LBS 21KGS F

3'5FT 22LBS 10KGS F
 ARE YOU A MEMBER OF ORGANIZATION IN THE
INFANT FEEDING (0-2 Y/O) KNOW EXISTING ORGANIZATION PRESENT HEALTH PROB. IN BRGY
COMMUNITY

SA-Substance abuse (drugs, alcohol drinks,

BF-Breast Feed BF-Bottled Formula M- etc.)
YES NO YES NO
Mixed WD-Waste disposal PO-Peace and order
Others:

M
 NO NO OTHERS

NO NO OTHERS

YES NO DRAINAGE F

YES NO DRAINAGE F

YES NO DRAINAGE F

OTHERS

NO NO
NO NO PO

NO NO PO

NO NO PO

NO NO PO

NO NO PO

NO NO PO
TO WHOM DO YOU CONSULT YOUR NEED/PROB.

F-Family R-Relatives N-Neighbors

F-Friends
BO-Baranggay Officials
Others:
 F

F
F

R,F