OUR LADY OF GUADALUPE COLLEGES, INC.
COLLEGE OF NURSING
COMMUNITY HEALTH SURVEY FORM
FAMILY NO:
FAMILY SIZE: 10
FATHER:
Marcelo J. Sultan
RELIGION:
Roman Catholic
MOTHER:
Ma. Arlene J. Sultan
RELIGION:
Roman Catholic
ADDRESS: 536 Calbayog Street, Pasilio 1, Blk. 1 Lot 13, Mandaluyong City
NO. OF CHILDREN: 6
NAME
AGE
SEX
MARCELO J. SULTAN
MA. ARLENE SULTAN
MARCELO J. SULTAN JR.
KIT ARVY J. SULTAN
ALLAH MAE J. SULTAN
APRIL MAE J. SULTAN
GERALD J. SULTAN
ARA MAICA J. SULTAN
EXTENDED FAMILY
53
49
26
25
23
19
16
13
M
F
M
M
F
F
M
F
CIVIL
STATUS
MARRIED
MARRIED
SINGLE
SINGLE
SINGLE
SINGLE
SINGLE
SINGLE
AILYN BALUNOS
26
F
SINGLE
11
months
M
SINGLE
PRINCE ETHAN SULTAN
PLACE OF ORIGIN:
PLACE OF ORIGIN:
Davao
Bohol
LIVING: DEAD: 0 ABORTION: 0 STILLBIRTH: 0
EDUCATIONAL
ATTAINMENT
HS GRADUATE
HS GRADUATE
HS GRADUATE
COLLEGE LEVEL
COLLEGE LEVEL
COLLEGE LEVEL
GRADE 11
GRADE 8
DRIVER
HOUSEWIFE
VENDOR
N/A
SERVICE CREW
N/A
N/A
N/A
MONTHLY
INCOME
Php 9,000.00
N/A
Php 6,000.00
N/A
Php 15,000.00
N/A
N/A
N/A
DAUGHTER IN
LAW
HS GRADUATE
HOUSEWIFE
N/A
GRANDSON
N/A
N/A
N/A
RELATIONSHIP
HUSBAND
WIFE
SON
SON
DAUGHTER
DAUGHTER
SON
DAUGHTER
LENGTH OF RESIDENCY: 45 years
LENGTH OF RESIDENCY: 39 years
OCCUPATION
BCG
DPT
OPV
0-12 MONTHS
HEP B
AMV
REMARKS
Infant Feeding
Home Ownership
Excreta Disposal
Sources of Health Information
[ ] Breastfeeding
[ ] Bottle Feeding
[ ] Mixed Feeding
[ ] Owned
[ ] Rented
[ ] Rent Free
[
[
[
[
[
[
[
[
[
Family Planning
Types of Housing Material
Garbage Disposal
Sources of Health Care Services
[ ] Practicing
[ ] Not Practicing
[
[
[
[
[
[
[
[
[
[
[
[
[
Methods of Family Planning
(Practicing Only)
Ventilation
Water Supply Sources
[ ] Adequate
[ ] Inadequate
[ ] Level I Point Source
[ ] Level II Communal Faucet
[ ] Level III Water Works System
[
[
[
[
[
[
[
[
] Pills
] Depot/Injectable
] IUD
] Condom
] BTL
] Vasectomy
] Rhythm
] Withdrawal
] Strong
] Mixed
] Light
] Makeshift
] Level I Pit Latrines
] Level II Pour Flush
] Level III Flush Toilets
] Balot/Wrap and Throw
] Others Specify:
] DPS
] Open
] Burning
] Segregation
] River/Estero
] Health Center
] Hospital
] Mass Media
] Others Specify:
] Hospital
] Private Physician
] Health Center
] Others Specify:
Food Storage
[ ] Refrigerated
[ ] Not Refrigerated
[ ] Covered
[ ] Exposed
INFORMANT: MARIA ARLENE J. SULTAN
OUR LADY OF GUADALUPE COLLEGES, INC.
COLLEGE OF NURSING
COMMUNITY HEALTH SURVEY FORM
FAMILY NO:
FAMILY SIZE: 7
FATHER:
Nilo I. Omlang
RELIGION:
Roman Catholic
MOTHER:
Marcelina H. Omlang
RELIGION:
Roman Catholic
ADDRESS: 536 Calbayog Street, Pasilio 1, Blk. 1 Lot 13, Mandaluyong City
NO. OF CHILDREN: 6
NAME
AGE
SEX
CIVIL STATUS
RELATIONSHIP
NILO I. OMLANG
MARCELINA H. OMLANG
MARCNEIL H. OMLANG
MAYBELYNE H. OMLANG
46
45
24
23
M
F
M
F
Married
Married
MARRIED
MARRIED
HUSBAND
WIFE
SON
DAUGHTER
MARYLYN H. OMLANG
MARCGIL H. OMLANG
MARCLIEN H. OMLANG
20
13
7
F
M
M
SINGLE
SINGLE
SINGLE
DAUGHTER
SON
SON
EXTENDED FAMILY
EDUCATIONAL
ATTAINMENT
HS LEVEL
COLLEGE LEVEL
COLLEGE LEVEL
COLLEGE
GRADUATE
COLLEGE LEVEL
GRADE 8
GRADE 2
PLACE OF ORIGIN:
PLACE OF ORIGIN:
Samar
Mandaluyong City
LENGTH OF RESIDENCY: 38 years
LENGTH OF RESIDENCY: 45 years
LIVING: 5 DEAD: 1 ABORTION: 0 STILLBIRTH: 0
TRICYCLE DRIVER
HOUSEWIFE
DRIVER
N/A
MONTHLY
INCOME
Php 6,000.00
N/A
Php 9,000.00
N/A
N/A
N/A
N/A
N/A
N/A
N/A
OCCUPATION
BCG
DPT
OPV
0-12 MONTHS
HEP B
AMV
REMARKS
Infant Feeding
Home Ownership
Excreta Disposal
Sources of Health Information
[ ] Breastfeeding
[ ] Bottle Feeding
[ ] Mixed Feeding
[ ] Owned
[ ] Rented
[ ] Rent Free
[
[
[
[
[
[
[
[
[
Family Planning
Types of Housing Material
Garbage Disposal
Sources of Health Care Services
[ ] Practicing
[ ] Not Practicing
[
[
[
[
[
[
[
[
[
[
[
[
[
Methods of Family Planning
(Practicing Only)
Ventilation
Water Supply Sources
[ ] Adequate
[ ] Inadequate
[ ] Level I Point Source
[ ] Level II Communal Faucet
[ ] Level III Water Works System
[
[
[
[
[
[
[
[
] Pills
] Depot/Injectable
] IUD
] Condom
] BTL
] Vasectomy
] Rhythm
] Withdrawal
] Strong
] Mixed
] Light
] Makeshift
] Level I Pit Latrines
] Level II Pour Flush
] Level III Flush Toilets
] Balot/Wrap and Throw
] Others Specify:
] DPS
] Open
] Burning
] Segregation
] River/Estero
] Health Center
] Hospital
] Mass Media
] Others Specify:
] Hospital
] Private Physician
] Health Center
] Others Specify:
Food Storage
[ ] Refrigerated
[ ] Not Refrigerated
[ ] Covered
[ ] Exposed
INFORMANT: NILO I. OMLANG