FAMIL SURVE FORM

H D N .: A :

N .: B N .:

H F : F N .:

I. FAMIL STRUCTURE AND CHARACTERISTICS II. SOCIO-ECONOMIC AND CULTURAL FACTORS

N F C E
M P A G S B R E O R
 III. HOME LIVING & ENVIRONMENTAL CONDITION

A. H B. S E. T F

1. H O : 1. S : 1. T T :
OO O NA ASA O S
OR OD OP P
OR F OO : OS T
2. O : OO :
2. T H : OP 2. O :
OS OP OO
OM OS OS
OL 3. D S : 3. S C :
OJ OS
3. N R : OC O
O F. D A
4. P : OD 1. K :
O OB 2. C :
O C. K O
1. C F : O
5. L : OG S G. I &V C
O E OC OM
O E OE S OC
OO : OO : OE
2. D F : OO :
6. : OO H. T C G
OS OB 1. G S C :
OF ON
OP D. G D 2. H C :
1. R D : O
7. G S C : OC ON
OG OB 3. R F
OF OB
OP OO D 4. A /A H
2. G C : C F (D B ):
OO
OC
ON
 IV. HEALTH AND MEDICAL HISTORY

1. Present Illness 4. Source of Medical Care

Disease Medical
Name Remarks Regarding Pregnancy and Lactation:
Suffered Attendance
O Health Center
O Hospital
O Private Physician
O Private Clinic
O Others:_______________________

5. Nutrition:
a. Infant Feeding: O Breastfed O Bottlefed O Mixed Feeding
b. Type of Milk: O Powdered O Evaporated
c. Age Supplemental Feeding Started:_________________________
2. Past Illness
d. Type of Foods Given:
Disease Medical ___________________________________________________________
Name Remarks
Suffered Attendance ___________________________________________________________
___________________________________________________________
6. Food beliefs regarding Pregnancy and Lactation:

a. Foods not given during pregnancy:

___________________________________________________________
___________________________________________________________
___________________________________________________________
b. Foods not given to mother during lactation:
___________________________________________________________
3. Immunization Status of Children ___________________________________________________________
Disease ___________________________________________________________
Name Vaccine Given Remarks c. Foods and drinks given to mother during pregnancy & lactation:
Suffered
___________________________________________________________
___________________________________________________________
___________________________________________________________

7. Food Preference and habits of the family:

___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
 V. OTHER PERTINENT QUESTIONS

S R

P O

L R

F S

P H S B

S H I
 VI. FAMIL COPING INDE

FAMIL : DATE:

ADDRESS: HEALTH DEPARTMENT :

A J
F C A P S P S

P I 1 2 3 4

T C 1 2 3 4

K H C 1 2 3 4
A P G
H 1 2 3 4

H A 1 2 3 4

E C 1 2 3 4

F L 1 2 3 4

P E 1 2 3 4

C R 1 2 3 4

C :