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HH Profile Form.pdf
- 1. Relation -ship of members toHH Head Sex Date of Birth Civil Status Philhealth ID Number Member -ship Type Philhealth Category Medical History Last Mestrual Period (LMP) Educational Attainment Religion Remarks Using any FP method? Family Planning Method used FP Status Last Name First Name Middle Name Age Class Age Class Age Class Age Class N - None K - Kinder ES -Elem Student EU - Elem Undergrad EG - Elem Graduate HS - HS Student HU - HS Undergrad HG - HS Graduate V - Vocational Course CS - College Student CU - College Undergrad CG - College Graduate PG - Postgraduate Example: Roman Catholic, Christian, INC, Catholic, Islam, Baptist, Born Again, Christian, Buddhism, Church of God, Jehovahs Witness, Protestant, Seventh Day Adventist, LDS- Mormons, Envangelical, Pentecostal, Unknown, Other Write additional notes such occupation, nutritional status, or any other detail related to each member of the household Y - Yes N - No Choose from the following: COC, POP, Injectables, IUD, Condom, LAM, BTL, Implant, SDM, DPT, Withdrawal, Others NA - New Acceptor CU - Current User CM - Changing Method CC - Changing Clinic DO - Dropout R - Restarter 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter N-Newborn AB- Adult >25 y.o SC - Senior Citizen WRA - Women with Rep Age S- School Age (0-5 y.o.) A-Adolecent (10-19 y.o.) P-Pregnant AP- Adolecent Pregnant PP-Postpartum I-Infnat U-under 5 y.o. PWD -person with disability Classification by Age/Health Risk Group (Please provide the names of the members of the household starting from the household head followed by spouse, son/daughter (eldest to youngest), and other members 1 - Head 2 - Spouse 3 - Son 4 - Daughter 5 - Others, specify relation M - Male F - Female Write the birthday in this date format: mm/dd/yyyy M - Married S - Single W - Widow/er SP - Separated C - Cohabitation M - Member D - Dependent FEP - Formal Economy Private FEG - Formal Economy Government IE - Informal Economy N - NHTS SC - Senior Citizen IP - Indigenous People U - Unknown HPN - Hypertension DM - Diabetes TB - Tuberculosis S - Surgery Write the LMP in this date format: mm/dd/yyyy Relationship to HH Head: ⃝ Non-IP Household Name of Household Members Women of Reproductive Age (WRA) Type of Toilet Facility: Barangay: First Name: select from the following: Level I - Point Source Level II - Communal Faucet Level III - Individual Connection Others - For doubtful sources, open dug well etc. *write the type of water source in the box provided above select from the following: A - Pour/flush type connected to septic tank B - Pour/flush toilet connected to septic tank AND to sewerage system C - Ventilated Pit (VIP) latrine D - Water-sealed toilet *write the type of toilet facility in the box provided above E - Overhung latrine F - Open pit latrine G - Without toilet Household (HH) Number: Middle Name: Sitio/Purok: Last Name: ⃝ IP Household If IP Household, indicate Tribe: ⃝ NHTS 4Ps ⃝ NHTS Non-4Ps ⃝ Non-NHTS If NHTS, please indicate the NHTS No.: Type of Water Source: Household Information Name of Respondent Ethnicity (Please Tick) Socioeconomic Status (Please Tick) Environmental Health Data HOUSEHOLD PROFILING FORM Date of Visit (mm/dd/yyyy) Municipality/City/District: __________________________ Interviewed by: __________________________________ First Quarter: Second Quarter: Third Quarter: Fourth Quarter: Province: _______________________________________ Reviewed by: ____________________________________