BARANGAY HEALTH PROFILE

Notre Dame of Dadiangas University

COLLEGE OF NURSING

Barangay / Purok: Purok Bia-o Baranagay San Jose, General Santos City

Household No: __

Date: ____________

PERSONAL DATA
Name of respondent: ____Mrs. Z_________

Birthday: __June 6, 1958___ Status: Married Educational Attainment: ____College

Graduate_______

I. GENERAL HOUSEHOLD DATA

A. Total No. of Children 6
B. List of Household members
Member
s

B-day
Y/M/D

Statu
s

Occupati
on

Sex

Mr. Z

June 6, 1958

Marri
ed

Farmer

Male

Z1

August 5,
1994

Singl
e

Student

Male

Z2

June 15,
1996

Singl
e

Student

Fem
ale

Educationa
ll
Attainment
High
School
Level
High
School
graduate
High
School
Level

Religio
n

Rel. to
Resp.

Imm.
Status
C/inc/N

Islam

Husba
nd

Islam

Son

Islam

Daugt
her

Dewormi
ng
Date

Weig
ht

II. Economic Data

A. Source of income: dressmaking and farming______
Estimated monthly income: 500 1000php
B.

(including extra sources)_____________________________________________________________

1. Land:
Owned( )
Rented( / )
Tenanted( )
2. No. of hectares_____
3.Type:
Plain( / )
Rollin( )
C. Products, is land is farmed___________________________________________________________________
D. Type of Housing: Concrete( ) Ordinary( )
Owned( / )
Rented( ) Mixed ( / ) Scrap( ) Light ( )
E. Household Appliances (list)

1. _____None_________
2. __________________

6. __________________
7. __________________

NS

3. __________________

4. __________________
5. __________________

8. __________________
9. __________________
10. _________________

1. ________________________
4. ________________________

F. Animal Raising (list)

2. ________________________
5. ________________________

3. ________________________
6._________________________

G. Transport facilities: Owned( )

Rented or Others( / ) : tricycle or habal2x
H. Water:
Bought( )
Free( / ) : irrigation
III. ENVIRONMENTAL DATA
A. Toilet Facilities:
Owned( / )
Shared( )

D.

None( )
( ) Flush Septic tank
( / ) Pit Privy
( ) Bedpan
( ) Water sealed
( ) Unsanitary
( ) Anywhere
B. Source of drinking water supply
( ) deep well more than 100 ft.
( ) Shallow less than 100 ft.
( ) spring
( ) dug well
( ) pipe system
( / ) others: river
B.1 Water container used
( /) with cover ( ) without cover
C. Drainage
( / ) open
( )blind
Garbage Disposal
( ) compost pit
( ) burying
( / ) burning
( / ) dumping
anywhere
D.1 Garbage Container used:
( ) with cover
( / ) without cover
E. Home Gardening
( ) herbal
( ) vegetable
( ) none

( )

IV. MEDICAL/HEALTH DATA

A. Common disease (actual)/ common treatment list:

1. ___Flu____________________________________
2. ___Arthritis
____________________________
3. ____Hypertension____________________________

C.

4. __________________________________________
B. Immediate source of medical care
Venue
Persons
( ) NHS
( / ) Hilot
( ) CHO
( ) BHW
( ) CHO Doctors
( ) Private clinics
( ) RHM
( ) Hospital Doctor
( ) Hospital
( ) PHN
( ) others
Family Planning
( ) Acceptor
( / ) Not
Method : ________________________
( ) continuous user
( / ) Not
D. Pregnancy: Age of Gestation (AoG)_____________________
EDC__________________________
E. Lactating
( ) Yes
( / ) No
F. Death in the family
YEAR
AGE
SUSPECTED CAUSE

G. Other pertinent observations/ informations like presence of personality disturbances:

( ) Drug Addiction
( ) Alcoholism
( ) Smoking
H. Additional Notes
I. Disable Member of the family:
(please indicate what kind of disability)
1. ____________________________________________________________________
2. ____________________________________________________________________