Barangay Health Profile

BARANGAY HEALTH PROFILE Department of Nursing Notre Dame of Dadiangas University – Nursing Barangay / Purok: _______________________________________

Household No.______________

Date: June 24, 2006

PERSONAL DATA Name of respondent: ________________________ Birthday: ______________ Status: ___________ Educational Attainment: ___________

I. GENERAL HOUSEHOLD DATA A. Total No. of Children____________ B. List of Household members Members

B-day Y/M/D

Status

Occupation

Sex

Educn’tl Attainment

Religion

Rel. to Resp.

Imm. Status C/inc/N

Deworming Date

1. 2. 3. 4. 5.

II. Economic Data A. Source of income__________________________ Estimated monthly income________________ (including extra sources)_____________________________________________________________ B. 1. Land Owned( x ) Rented( ) Tenanted( ) 2. No. of hectares_____ 3.Type: Plain( ) Rollin( x ) C. Products, is land is farmed___________________________________________________________________ D. Type of Housing: Concrete( ) Ordinary( x ) Owned( ) Rented( ) Scrap( ) E. Household Appliances (list)

1. 2. 3. 4. 5.

__________________ __________________ __________________ __________________ __________________

6. __________________ 7. __________________ 8. __________________ 9. __________________ 10. _________________

Weight

NS

F.

Animal Raising (list) 1. ________________________ 4. ________________________

G. Transport facilities: H. Water:

Owned( ) Bought( )

2. ________________________ 5. ________________________

3. ________________________ 6._________________________

Rented or Others( ) Free( )

III. ENVIRONMENTAL DATA A. Toilet Facilities: Owned( )

Shared( ) 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 B.1 Water container used ( ) with cover ( ) without cover C. Drainage ( ) open ( )blind D. 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:

B.

C. D. E. F.

1. ___________________________________________________ 2. ___________________________________________________ 3. ___________________________________________________ 4. ___________________________________________________ 5. ___________________________________________________ Immediate source of medical care Venue Persons ( ) NHS ( ) Hillot ( ) CHO ( ) BHW ( ) CHO Doctors ( ) Private clinics ( ) RHM ( ) Hospital Doctor ( ) Hospital ( ) PHN ( ) others Family Planning( ) Acceptor ( ) Not Method_________________________ ( ) continuous user ( ) Not Pregnancy: Age of Gestation (AoG)_____________________ EDC__________________________ Lactating ( ) Yes ( ) No Death in the family YEAR AGE SUSPECTED CAUSE

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

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