Reach 52 (Profiling)

First Name: _________________________

Middle Name: _______________________
Last Name: _________________________
Gender: ___________________________
Date of Birth: _______________________
Contact Number: ____________________
Country: ___________________________
Region: ____________________________
Province: __________________________
Municipality: ________________________
Landmark: _________________________

What is your average household income per month? Including all sources of income
such as regular or occasional/part time employment, personal business, remittances
from relatives abroad, pensions and other financial support *
o P4,300 and below
o P4,301 - P7,200
o P7,201 - P12,400
o More than P12,400
o Refused to answer
Height (cm): _________
Weight (kg): _________

Do any of your family members have existing medical conditions? *

o Alzheimer or other dementia
o Arthritis
o Asthma
o Cancer
o (COPD)
o Chronic Obstructive Pulmonary Disorder (COPD)
o Cirrhosis of the Liver
o Coronary artery disease
o Diabetes
o Diarrhea diseases
o Heart Attack
o Hepatitis A
o Hepatitis B
o Hepatitis C
o HIV or AIDS
o Hypertension
o Ishaemic Heart Disease
o Kidney Disease
 o Lower Respiratory Infections
o Malaria
o Measles
o Stroke
o Paralysis
o Pneumonia
o Tuberculosis
o None of the above

Which statement best describes your average frequency of drinking alcohol *

o I have never consumed alcohol
o I have not consumed alcohol in the last 12
o months
o I drink alcohol about once a month or less
o I drink alcohol 1 to 3 times per month
o I drink alcohol 1 or 2 times per week
o I drink alcohol 3 or 4 times per week
o I drink alcohol 5 or 6 times per week
o I drink alcohol daily
o I do not wish to answer this question

Do you smoke or use any tobacco products? *

o No
o No but people often smoke around me
o Yes, 1-5 per day
o Yes, 10 - 20 per day
o Yes, over 20 per day
o I do not wish to answer this question

How many amenities do you have?

o Electricity
o Water supply
o Proper ventilation
o Hand washing facilities
o None of the above
o I do not want to answer this question, thank you

Have you been to a health facility in the past year?

o Yes
o No

Have you received any of these vaccinations? *

o COVID-19 Vaccine
o Flu Vaccine
 o Haemophiles influenzae type b (Hib) vaccine
o Hepatitis A vaccine
o Hepatitis B vaccine
o HPV (Human papilloma virus) vaccine
o Meningococcal vaccine
o MMR (Measles, mumps, rubella) vaccine
o Pneumococcal vaccine
o Polio vaccine
o Rota virus vaccine
o Tdap (Tetanus, diphtheria, pertussis) vaccine
o Varicella (for chickenpox) vaccine
o Zoster recombinant vaccine (RZV)
o others

Overall, how would you rate your mental health?

o Poor
o Somewhat poor
o Average
o Good
o Excellent
o I do not want to answer this question

Which of the following products and services would you be interested in?

o Subscribe to Health
o Articles & Videos
o Get health information via
o Facebook & Whats App
o Phone reminders on healthier lifestyles
o Attend local health events
o Doctor visits to Community
o Peer-to-peer events (connecting to other patients with same conditions as me)
o Access to Doctors via phone/video calls
o Access to Personal health services in my home (ie.
o Blood pressure/blood glucose check)
o Access to diagnostics/ screening services
o Affordable medicines
o Vaccines
o Nutrition and wellness products