TALLY SHEET DEMOGRAPHIC VALUE Number of Family Members 3 4 5 5 and above Sex F M Age 0-5 6-10 11-15 16-20

21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 65 and above Civil Status C S M MS

W Wr Religion RC P INC BAC JW I OTHERS Education P EL EG HL HG V S CL CG PG NONE Occupation Type E RF RP C CW CE SE

S UE Location I IM/C O OFW Place of Work OF FC FL I Place of Origin NCR CL NL SL V M Type of Family Nuclear Dyad extended homosexual Single parent Cohabiting/common law Matriarchal Matricentric Patriarchal Patricentric

Egalitarian Patrilocal Matrilocal Neolocal SOCIO-ECONOMIC, CULTURAL, AND ENVIRONMENTAL 2. Economic indicator Monthly family income (combined) Less than 5000 5000-10000 10001-15000 15001-20000 20001-25000 25001-30000 30001-35000 35001-40000 40001-45000 45001-50000 50001 and above Financial source for family expenditures Employment Help from relative/friends Business Pension Others Monthly family expenditure Less than 5000 5000-10000 10001-15000 15001-20000 20001-25000

25001-30000 30001-35000 35001-40000 40001-45000 45001-50000 50001 and above Priorities and expenditures 1 Food Health Clothing Recreation Education Savings Utilities others Adequacy of family income adequate Not adequate 3. Cultural indicator Cultural indicator regarding illness Physiologic factors Supernatural phenomenon Punishment from God Other person Change in weather Cultural belief Restored by God/supernatural belief By faith healers By supernatural power 2 3 4 5 6 7

By health personnel Cultural practices Always sometimes Does not Community involvement Actively joins Does not actively join 4. Environmental indicator Home Ownership Owned Rented Rent-free Least to own Construction materials used Light mixed Strong Number of rooms and person used for sleeping 1 2 3 More than 3 None Adequacy of space Adequate Inadequate Lighting facility Electricity kerosene

Others Adequacy of lighting Adequate Inadequate Ventilation Adequate Inadequate General sanitary condition Very satisfactory Satisfactory Poor Needs improvement Drinking water supply Ownership Private/own household Public Source Deep well Local water district Commercial Potability Yes No General household use Storage None Large covered container w/ faucet Large uncovered container w/out faucet Others Food Storage/Cooking Facilities Storage

Refrigerator Cabinet Basket Table covered Uncovered Cooking facility Electric stove Gas stove Firewood/charcoal Sanitary Condition Very satisfactory Satisfactory Poor Needs improvement Garbage/waste disposal Refuse and garbage Storage Container Covered Open Plastic bag None Waste segregation Practiced Not practiced If practiced, method of disposal (biodegradable) Hog-feeding Collected Open dumping Composting

Burial in pit Non-biodegradable Recycle Reuse Collected Open burning Open dumping Others Reason for practicing Environmental friendly Use for business Barangay ordinance w/c is strictly monitored Others If not practiced, method of disposal Open dumping Garbage collection Burial in pit Open burning Others Reason for not practicing Not aware of effects Long-time practice of family No time to do it Not a barangay ordinance/not strictly monitored Toilet Facilities Ownership Owned Shared/public None Type ballot system

Overhung latrine Bored-hole latrine Open pit privy Anitpolo type Closed pit privy Water-sealed Others Location from water source Less than 20 ft 20 ft beyond Sanitary condition Very satisfactory Satisfactory Poor Needs improvement Drainage System Open drainage Blind drainage None Condition Flowing Stagnant Presence of animals that are rabies carriers Dogs Cats Others Where kept Inside the yard Free outside Yes With regular vaccination No

Practices/measures done to insects to control insects/vectors of diseases Fumigation Insecticides Setting traps Cleaning the yard None yes Presence of breeding sites HEALTH AND ILLNESS PATTERN Hygiene Practiced Taking a bath regularly Brushing the teeth Handwashing before & after eating Nail cutting Use of hygienic products Ear cleaning Regular change of clothes Rest and sleep Sleeps at least 8 hours a day Takes a nap/rest period w/in the day Exercise Perform regular exercise everyday Performs recreational activities Health promotion activities Has regular medical checkup(Once a year) Has regular dental checkup(every 6 months) Use of Safety Precaution Use of safety devices when necessary Yes Is there a member of the family who is a cigarette No Not Practiced no

smoker? Age 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 65 and above Age started smoking 11-15 16-20 21-25 26-30 31-35 36-40 Reason Curiosity Stress Peer pressure Others Yes Use of prohibited drugs Age no

0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 65 and above Age started using 11-15 16-20 21-25 26-30 31-35 36-40 Reason Curiosity Stress Peer pressure Others Drinks Alcoholic beverages Age 0-5 6-10 11-15

16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 65 and above Age started drinking 11-15 16-20 21-25 26-30 31-35 36-40 Nutritional Status Weight for Age 0-83 months compared with IRS adopted for Filipinos N UW OW 9-19 years old N MU U O Adults U

N OW Ob Dietary History Foods usually/most taken First choice Meat only Fish only Vegetable only Mixed Others Number of servings 1 2-3 4-5 and above Second choice Meat only Fish only Vegetable only Mixed Others Number of servings 1 2-3 4-5 and above Reason for choices Think its healthy Personal belief/practice Own preference Health condition Affordable

Reason for not choosing other options Not healthy Personal belief/practice Own preference Health condition Not affordable How frequent is the intake? Everyday Every 3 days Once a week Others How is food prepared for mealtime? Prepared at home Bought outside How often? Everyday Every 3 days Once a week Others If bought outside, is it from the? Restaurant/fast food Carinderia Food cart Reason Convenience cheaper Healthy Variety of choices Others Takes/eat canned/preserved food Everyday

Every other day Every week Sometimes Never Takes/eat fried foods Everyday Every other day Every week Sometimes Never Drinks carbonated beverages Occasionally Weekly Everyday Beliefs and Practices Personnel mostly consulted in times of sickness/illness Doctor Nurse Midwife Hilot Albularyo Faith healer Elderly Measures taken in times of sickness/illness Private health worker Rural health team Known community healer Self-medicate None Medication/treatment taken in times of sickness/illness Prescribed by doctor

Over the counter/self-medication herbals Others Immunizations (0-12 months) yes BCG DPT1 DPT2 DPT3 Hepa B1 Hep B2 Hep B3 OPV1 OPV2 OPV3 Measles Complete accdg to age FIC With Prenatal checkup Regular Tetanus toxoid vaccination Family Planning yes Acceptor Reason for accepting Good for health of family Religious belief Personal belief Influence by others No Irregular Without No

Others Reason for not accepting Bad for health of family Religious belief Personal belief Influence by others Others Methods used Natural Artificial Permanent Health Indicator Morbidity Gender F M Age 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 65 and above

Cause Environment Food Water Hygiene From other people Others with Intervention Result Become better became worse Mortality Gender F M Age 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 65 and above Without

Pregnant Infant Cause Accident By old age Disease Others If pregnant Labor and delvery blood loss infections Unsafe abortions eclampsia Others If infant Congenital defects Preterm birth and low birth weight Maternal complications of pregnancy Complictions of the umbilical cord, placenta, membranes Others Presence of Non-Communicable disease Heart disease Cancer Kidney disease Asthma Diabetes Diarrhea Arthritis Hypertension Hemophila

Others Age 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 65 and above Gender F M Presence of communicable diseases Chicken pox TB Measles Hepatitis Fever Cough Cold Skin disease Flu Mumps STD

Others Age 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 65 and above Gender F M Blood Pressure record for ages 35 and above Normal 35 36-40 41-45 46-50 51-55 56-60 61-65 65 and above Awareness of health services offered by the BHU/RHU Hypertensive Hypotensive

Aware Unaware Political/leadership Patterns Recognized leader Formal/elected Captain Kagawad Non formal Elderly BHW Influential person Religious leader Neighbor Conditions/events/issues that cause social conflicts/upheavals within the community Gossip Personal/familial conflict Drugs Riot Alcohol drinking Others Practices/approaches which are effective in setting issues and concerns within the community Settlement among involved parties Bgry hearing Endorsed local police Others