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Sex

Male
Female

1
2

Religion
Roman Catholic
Iglesia ni Cristo
Mormon
Islam
Protestantism
Others

1
2
3
4
5
6

BMI Interpretation
Normal
Overweight
Obese
Underweight
Severly underweight

1
2
3
4
5

Water Intake
<3 glasses per day
4-7 glasses per day
8 glasses per day
Drinking Water Source
Deep well
Local Water System
Others
Hygienic Practices
Hand washing at critical times
Presence of permanent HW stations
Bathing Frequency
1-3x per week
4-6x per week
Every day

Nutritional History

Oral Hygiene

Seldom
Every 3 months
1-2x per month
1-3 days per week
4-7 days per week

1
2
3
4
5

Meal Frequency per day


1/day
2/day
3/day
>3/day

1
2
3
4

Less often
Once a day
2-3x per day

1
2
3

ource
1
2
3
Yes
1
1

ncy
1
2
3

1
2
3

No
0
0

F1.1

F1.2

F1.3

F1.4

F1.5

First Name

Last Name

Date of Birth

Age

Sex

Melanie
Ignacio
Paulo
Angela
Angelica
Jovel
Janjan
Yesha Mae
Lyca
Justine
Kissing

Dionisio
Shikim
Rapada
Andes
Andes
Sison
Andes
Cartago
Urbano
Nazareth
Gagami

12/16/2002
6/12/2004
4/12/2006
12/8/2013
12/19/2002
12/27/2005
N/A
8/10/2007
11/4/2003
1/9/2002
N/A

12
11
9
1 11/12 months
12
9
5
8
12
13
7

2
1
1
2
2
2
1
2
2
1
1

F1.6

F1.7

F1.8

A1.1

Religion

Education

Address

Weight

2 Grade 6
1 Grade 4
1 Not elicited
1
1 Grade 6
1 Grade 2
1
1 Grade 3
1 N/A
1 N/A (APEC School)
1 N/A (DCS Elem.)

Bicot St., Payatas


Bicot St., Payatas
Bulacan St., Payatas
Bicol St., Payatas
Bicol St., Payatas
Bicol St., Payatas
Bicol St., Payatas
Bicol St., Payatas
Bicol St., Payatas
Visayas St., Payatas
Bicol St., Payatas

34.4
22.6
20.6
3.6
33
34.8
16.4
30.4
34.4
32
14.8

A1.2

A1.3

A1.4

Height

BMI

Interpretation (BMI-for-age)

1.46
1.25
1.22
0.77 N/A
1.47
1.29
1.06
1.25
1.48
1.43
1.09

16.14
14.464
13.84

1
1
1

15.27
20.91
14.6
19.456
15.7
15.65
12.46

1
2
1
2
1
1
1

A1.5

A1.6

A1.7

Interpretation (Height-for-age)

Temperature

Heart Rate

-1
0
-1
0
0
0
0
0
-1
-2

36
36.3
36.3
36.3
36.7
36.3
36.1
36.4
36.4
36.5
36.5

70
80
88
72
68
94
92
108
98
103

A1.8

B1.1

B1.2

B1.3

B1.4

Respiratory Rate

Rice

Fish

Meat and Poultry

Vegetables

20
18
40
24
22
23
18
22
22
20

5
5
5
5
5
5
5
5
5
5
5

4
4
2
4
5
1
4
4
4
5
5

4
5
1
4
4
4
5
5
4
4
4

5
5
5
4
4
5
3
4
5
4
5

B1.5

B1.6

B1.7

B1.8

B1.9

B1.10

Fruits

Milk Products

Seafood

Processed Foods

Canned Goods

Noodles

4
4
5
4
1
4
4
4
4
4
5

1
1
1
5
1
1
1
1
4
1
1

1
3
1
1
1
1
1
4
3
1
1

4
4
4
5
4
3
1
4
5
4
5

4
4
1
4
4
5
4
4
5
4
4

4
5
4
5
1
4
4
4
5
4
3

B1.11

B1.12

B1.13

Junk Foods

Others

Interviewer Comments (Indicate other food types)

5
5
5
5
5
4
4
1
4
4
4

Candy, Chocolates

B2

B3

B4

C1.1

Meal Freq./day

Water Intake

Drinking Water Source

HW at Critical Times

3
2
2
2
3
3
1 N/A
2
3
3
1

2
1
2
2
2
1
1
1
2
1

2
2
2
3
2
2
2
2
2
3
2

1
1
1
0
1
0
1
1
1
0

C1.2

C1.3

C1.4

Permanent HW stations

Bathing frequency

Oral Hygiene

1
1
1

3
3
3

3
3
3

0
1
1
1
1
1
1

3
2
1
3
2
3
3

2
2
1
3
3
2
3

D1
Interviewer Comments (Chief Complaint / Pertinet Findings)

Blurry vision, dizziness (1-5 minute duration) upon waking-up and straneous activities, head lice infes
Impacted cerumen
Lice infestation, impacted cerumen
Viral URTI
Asthma, cough, impacted cerumen
Chest pain after eating and performing straneous activities, lice infestation, impacted cerumen
Weakness, head lice infestation
URTI, head lice infestation, impacted cerumen
Cough, heal lice infestation, impacted cerumen
URTI, impacted cerumen
Difficulty in breathing

us activities, head lice infestation, impacted cerumen

n, impacted cerumen