MINDANAO STATE UNIVERSITY BUUG COLLEGE OF HEALTH SCIENCES

IPIL EXTENSION
Sanito, Ipil, Zamboanga Sibugay

FAMILY PROFILE
House #: Name of Respondent: Educational Attainment: Name of husband/wife: No. of children: Age: Age:

A. FAMILY INCOME MONTHLY INCOME MOTHER FATHER OTHERS y y Residential status: Permanent Temporary Type of house unit: Single detach Apartment/condo Multiple Dwelling units Ownership of Dwelling units: Owned Rented Occupying free w/o consent Material used (house) Concrete Wood Mixed wood with concrete SOURCE OF INCOME y y y y

C. ENVIRONMENTAL SANITATION Type of CR _________________ Garbage Disposal system _________________ Source of water: __________________ If not NAWASA, why? _______________________________________

How are you going to handle excess foods? _______________________________________ y Livestock Raising  Type of livestock ______________________ y Pet handling YES NO  Do you have pets? y y y If yes, what kind of pet? _____________ If dog, is it vaccinated with anti-rabies? YES NO

y y

y y y

B. NUTRITON INFORMATION Does the family have backyard garden? YES NO Percentage of income appropriate for food.______ Usual Diet Glow foods Grow foods Go foods

y y y y

D. FAMILY PLANNING Are you using family planning method? YES NO If yes, what type of FP methods? Natural FP, what type? ________________ Artificial FP, what type?________________ Reasons for using FP method: _______________________________________ Reasons for stopping use of FP methods: _______________________________________ Knowledge of FP before marriage: _______________________________________ Source of information regarding FP:____________________________________

Are members of the family uses iodized salt? YES NO

E. MATERNAL AND CHILD HEALTH CARE  MOTHERS Healthworker examination: YES NO  During pregnancy  After pregnancy     Prenatal visits COMPLETE INCOMPLETE TT injection received Vitamin A supplementation Iron supplementation

G. STI/HIV/AIDS YES y y y NO Is there a family member who has Known to have these infections? Do they have the knowledge on the signs and symptoms of these infections? Methods practiced to avoid the infection/s: ____________________________________

H. COMMUNICABLE AND NONCOMMUNICABLE DISEASES COMMUNICABLE NON-COMMUNICABLE

 CHILDREN  Number of child at home below 6 years old and below:____ YES NO  Breastfeeding:  Formula feeding:  Mixed Bottle:  Are the infant have completed the EPIs? COMPLETED INCOMPLETE UNRECALLED

y y y

Who diagnosed the disease? ____________________________________ Prescribed or OTC medication: ____________________________________ If OTC, what are the medications? ____________________________________

 BABIES  Is the Baby s Weight taken within the previous 6 months? YES NO

I. INFORMATION , EDUCATION,COMMUNICATION y Source of information: ________________ y Usual information heard:_______________ y Application of learning to family: YES NO

F. ADOLESCENT AND REPRODUCTIVE HEALTH y Is there a member of the family YES who got married 18 years old and below? y Is there pregnant 18 years old and below? y Any miscarriages experiences?

NO

J. COMMUNITY INVOLVEMENT AND PARTICIPATION ____________________________________ y Overall, what are the major problems in the community that you wish to be solved? ____________________________________ y What do you think are the health problems in the community? ____________________________________ y What are the health programs that you want to be implemented in your community? ____________________________________