Professional Documents
Culture Documents
SURVEY QUESTIONNAORE
LIFESTYLE:
Number of Smokers
CIGARETTE CONSUMPTION
NO DURATION CONSUMPTION
AGE
. Week Month Year Sticks Packs
84
Number of Alcohol Drinkers
ALCOHOL BEVERAGE
FREQUENCY CONSUMPTION DURATION
NO. AGE # of # of
Daily Weekly Occasionally Week Month Year
Glasses Bottles
85
ADVENTIST UNIVERSITY OF THE PHILIPPINES
COLLEGE OF HEALTH
POPULATION PROFILE
86
Sources of Income of the Head of the Family Monthly Income
[ ] Salary
[ ] Sales Head of the Family:
[ ] Fees ____________________
[ ] Rentals
[ ] Pension Gross Family Income:
[ ] Relatives ____________________
[ ] Commission
[ ] No Income
ENVIRONMENT PROFILE
87
Water Storage for Cooking
[ ] Jug [ ] With Cover
[ ] Drum [ ] Without Cover
[ ] Bottles
[ ] Pail
[ ] Not Storing
[ ] Others, specify_______
HEALTH PROFILE
88
INFANT IMMUNIZATION (0 12 Months)
BCG
With Without
MEASLES (9 12 months)
89
With Without
No.
HEPA B
No. 1 2 3
With Without With Without With Without
DPT
No. 1 2 3
With Without With Without With Without
OPV
No. 1 2 3
With Without With Without With Without
90
ILLNESSES/DISEASESES (For the past 6 months)
No. Probable Confine Not Confined Herbal Remarks
Diagnosis d Used
[ ] NOT USING
Reason:
( ) Hospital ( ) Private Clinic
( ) Albularyo ( ) No one left at home
( ) Time restraint ( ) Not known to family
( ) Difficulty in travel ( ) Others, specify________________________
[ ] NOT USING
Reason, specify:___________________________________________________________
ANTEPARTUM
Trimester: [ ] 1st [ ] 2nd [ ] 3rd
TETANUS TOXOID (Pregnant only)
[ ] With Dose: 1 2 3 4 5
[ ] Without
LIFESTYLE:
CIGARETTE CONSUMPTION
NO DURATION CONSUMPTION
AGE
. Week Month Year Sticks Packs
ALCOHOL BEVERAGE
FREQUENCY CONSUMPTION DURATION
NO. AGE Dail Occa- # of # of
Weekly Week Month Year
y sional Glasses Bottles