BRGY.

POBLACION FAMILY
PROFILE

Head of Family: Birthday:

Address: Occupation:

Spouse:

Birthday:

Occupation:

Phil. Health #:

NHTS #: Contact Number:

( ) 4PS ( ) NHTS ( ) LGU Sponsored ( ) MCCT ( ) Dep Ed ( ) OFW ( )

Non-PHIC

Marita Rel. to the

Children’s Name Birthday Sex Head of Tribe
l the family

Status
Type of toilet used ( ) Water sealed ( ) Open pit privy
Source of Water:
Garbage Disposal ( ) composting ( ) burning ( ) burying
Backyard Gardening ( ) yes ( ) no
Type of Housing:

Family Planning used: ( ) BDM/Natural ( ) Pills ()

IUD ( ) DMPA
( ) Implant ( ) BTL ( ) Vasectomy
( ) LAM

Municipality of Lake Sebu

Barangay Poblacion

CHILD RECORD
Child Record (Children 0-5 years old)

Name: Date of Birth: Sex:

Address:
Mother’s Name: Occupation:

PAST HISTORY OF THE CHILD

1. Delivery ( ) Normal ( ) Abnormal, pls. state
2. Birth Order Number ( ) Single ( ) Multiple
3. Delivered by ( ) Midwife ( ) Hilot ( ) Physician ( ) Other,

4. Past Diseases

To be filled up only for less than 2 years old or with abnormality

5. Age started teething 7. Stand without support

6. Sit with support 8. Walk 1st step

IMMUNIZATION HISTORY
RECOMMENDED AGE
VACCINE AT 1½ 2½ 3½ 12
9 MONTHS
BIRT MONTH MONTH MONTH MONTH
H S S S S
BCG
HEPATITIS
B
PENTAVALE
NT
ORAL POLIO
VACCINE
(OPV)
INACTIVATED
POLIO VACCINE
(IPV)
PNEUMOCOCCAL
CONJUGATE
 VACCINE
(PCV)
MEASLES,MUMPS,
RUBELLA (MMR)

Dat Complaints/ Findings/ Diagnosis Treatmen

e t
NBS date and result:
Birth Weight:
Length/Height:
Vitamin K:

Dat Complaints/ Findings/ Diagnosis Treatmen

e t