Republic of the Philippines

Barangay 5 Sagmin
Legazpi City

PROFILE OF BARANGAY HEALTH WORKER (BHW) FOR MONITORING/UPDATES

NAME OF RESPONDENTS: _____________________________ HOUSE

NUMBER_________
(pls. indicate complete name including
middle name)

RESPONDENTS CONTACT NUMBER: _____________________

HOUSEHOLD CHARACTERISTICS

(1) How many household members are overseas workers? ______

FIRST NAME MIDDLE LAST NAME BIRTHDA MARITAL OCCUPATIO
NAME TE STATUS N

(2) How many nuclear families are there in the household? _____ (pirang pamilya ang nakaistar sa harong)

(3) Is any member of the household pregnant? ______ (1- Yes, 2-No)
FIRST NAME MIDDLE NAME LAST NAME BIRTHDATE EXPECTED DATE
OF DELIVERY

(4) Is any member of the household a solo parent? _____ (1- Yes, 2- No)

(5) Is any member of the household have physical or mental disability? _____ (1- Yes, 2- No)

FIRST NAME MIDDLE NAME LAST NAME BIRTHDATE SOLO PARENT

ID NUMBER

FIRST NAME MIDDLE NAME LAST NAME BIRTHDATE TYPE OF P.W.D ID NUMBER
DISSABILITY

(6) Is any member of the household senior citizen? _____ (1- Yes, 2- No)
 FIRST MIDDLE LAST NAME BIRTHDA SENIOR COMORBIDITIES
NAME NAME TE CITIZEN I.D. NO. (e.g hypertensive,
diabetes, uti and etc.

(7) Members of the household who are vaccinated from covid-19

FIRST MIDDLE LAST BIRTHDA TYPE OF DATE OF DATE OF
NAME NAME NAME TE VACCINE (sinovac, 1ST DOSE 2ND DOSE
astrazeneca, etc.)

(8) Do you have boarders? _____ (Yes/ No)

FIRST MIDDLE LAST BIRTHDATE CONTACT OCCUPATIO LENGTH

NAME NAME NAME NUMBER N OF STAY

(9) Do you have Kasambahay? ____(Yes/No)

FIRST NAME MIDDLE NAME LAST NAME BIRTHDATE GENDER

(10) Do you have pet (Cat/ dog)? _______

LATEST DATE
BIRTHDA OWNER’ OF
NAME AGE GENDER BREED COLOR
TE S NAME IMMUNIZATIO
N
DEMOGRAPHY (P.S PAKI KUMPLETO PO NG PANGALAN FIRST NAME, MIDDLE NAME AT LAST NAME)

HEAD OF MEMBERS RELATIONSH FEMALE/ AGE MARITAL CURRENTLY GRADE/ OCCUPATIO COMORBIDIT
THE FAMILY OF THE IP TO THE MALE STATUS ATTENDING YEAR N OR IES
(FIRST, MIDDLE, FAMILY HOUSEHOLD SCHOOL? BUSINESS
LAST) (FIRST, MIDDLE, (WIFE,
LAST) DAUGHTER, SON, (hypertensive,
NIECE ETC.) Yes/no (Teacher, nurse,
sari-sari store, diabetes, allergy atc.)
vendor etc.)