Republic of the Philippines
Eastern Samar State University
COLLEGE OF NURSING
A. SOCIO-DEMOGRAPHIC PROFILE
Respondent:________________________________
Date of Interview:___________________
Address:__________________________________________________________
Relationship
LI
Date of Birth
Age Sex
Civil
Name of the family member
(A2)
N
(A3)
(A4
(A5
Status
(A1)
E
)
(A6)
N
O
F M
MM
DD
YY
.
1
2
3
4
5
6
7
8
9
1
0
1
1
1
2
L
E
G
E
N
D
1.Wife
2.Husband
3.Mother
4.father
5.Daughter
6.Son
7.Nephew
8.Niece
9.Grandson
10
Granddaugh
ter
Others:___
T
o
t
a
l
T
o
t
a
l
1Single
2Marrie
d
3Widow
4Legally
Separa
ted
Household Serial No:________________________________
Length
of
residen
cy (A7)
Religion
(A8)
Type of
Family
(A9)
Interviewer:_____________________
Highest
Can Read
Occupation
Educational
and Write
(A11)
Attainment
(A10)
YES
1-(1-5
yrs.)
2-(5-10
yrs.)
3-(10-15
yrs.)
4- 15
yrs.
above
1-RC
2-Born Again
3-INC
4-Mormons
5.Datingdaan
6.Latent Day
Saint
7.Muslim
8.Protestant
Others
specify:____
EASTERN SAMAR STATE UNIVERSITY- COLLEGE OF NURSING CLASS 2018- BATCH JADE
1-Nuclear
2-Extended
3-Blended
4Cohabitaton
5-Adaption
Others
specify:____
_
1-No formal
schooling
2-Pre school
3-Elem level
4-HS level
5-College level
6-Vocational
7. Elem.Grad.
8.HS graduate
9. College
Grad.
10.Ph.D
Others______
Place of
Origin
(A12)
NO
1-Teacher
2-Govt.
Employee
3-Fisherman
4-Carpenter
5Construction
6-Self
employed
7-Student
8-Farmer
9.None
SERIAL NO.________________
1-Native
2-Migrant
3-Immigrant
Others
specify:____
Page 1 of 4
Republic of the Philippines
Eastern Samar State University
COLLEGE OF NURSING
B. SOCIO-ECONOMIC PROFILE
Source of Income
(B1)
4P’s Membership
Estimated Monthly
Income (B3)
Monthly
Expenditures
(B4)
Budget Allotted to
House Expenses
(in %) (B5)
Type of Flooring
(B6)
Ventilation
(B7)
Source of
Internet
(B8)
YES_____
NO______
1-Salary
2-Business
3-Pension
4-Fishing
5-Farming
Others specify:___
Method of
Relaxation (B9)
 Watching TV
 Playing Cards
 Reading
 Eating
Others
specify:_____
1. P 500 – P1,000
2-P 1001-P 3,000
3- P 3,001- P 5,000
4- P 5,001- P 10,000
5- P 10001 & above
Stress Management
Activities (B10)
 Talking with friends/relatives
 Household Chores
 Eating
 Drinking
Shopping
Others
specify:__________________
_
1-Below P 1,000
2-P 1001-P 3,000
3- P 3,001- P 5,000
4- P 5,001- P 10,000
5- P 10001 & above
__Food
__Education
__Medicine
__Electricity
__Housing
__Transportation
__Debt Payments
__Saving
__Personal
Discretionary
Traditions (B11)
Fiesta
 YES  NO
Brgy .San Isidro  YES  NO
Holy week
 YES  NO
Undas
 YES  NO
Christmas
 YES  NO
Others:__________
EASTERN SAMAR STATE UNIVERSITY- COLLEGE OF NURSING CLASS 2018- BATCH JADE
1-Cement
2-Tiles
3-Wood
4-Soil
Others specify:___
1-Windows
2-Electricfan
3-Air conditioned
4-Exhaustfan
Others specify:__
1-Wi Fi
2-Broadband
3-Pocket Wi Fi
4-Landline
Others specify:__
Social Concerns (B12)
(Please check as many as appropriate)
 Voting Rights Restrictions
 Violence against women and children
 Police Brutality
 Drug Substance/ abuse
 Child Abuse
 Illegal gambling
 Disaster Relief
 Graft and corruption
 Poverty
Teenage pregnancies
 Premarital Sex
Others:_________________________
SERIAL NO.________________
Page 2 of 4
Republic of the Philippines
Eastern Samar State University
COLLEGE OF NURSING
C. ENVIRONMENTAL INDICATORS
Water
Source
for
Drinking
(C1)
Deep
Well
Artesian
Well
Spring
Nawasa
Others
specify:__
____
Food Storage
(C2)
Composing
Burning
Waste
Segregation
Open dumping
Garbage
collection
None
 River
Others
specify:____
D. HEALTH PROFILE AND PRACTICES
LI
NE
NO
Cabinet
Plate
Refrigerator
None
Others
specify:____
Garbage Disposal
(C3)
B HepaC
B
G
1 2
DTwP
3 1 2 3
P
P
V
Water
Treatment (C5
 Chlorination
 Boiling
 Purification
 No
Treatment
IMMUNAZATION(D4)
Ro TDAP Influ Polio
Me
ta
enza
asl
Vir
es
us
1 2 1 2 3
1 2 3
Water Storage
(C6)
 water container
 Bottles
 drums
 Pail
Others
specify:_________
_
MMR
1 2 3
Vari
cell
a
He
paA
Toilet Facility (C7)
_____Owned
____Not
owned
HPV
1 2 1 2 3
INC.
TYPES:
Water Sealed
Hang Latrine
Burying
Overhang
Antipolo w/seal
cover
Sanitary pit
 Balot system
Others
Disaster
Management
(source of
information)(C4)
Others
specify:_________
________
Evacuation Area
(C8)
In Terms of
disaster
Awareness of
Evacuation Area
Aware
Not Aware
School
Church
Gym
Hospital
Municipal
Neighbors
Others
specify:________
___
Community Schistosomiasis Status (D7)
1. Any family member who has been diagnose?
__YES ____ NO
2 Has undergone/ Ongoing treatment?
__YES ____ NO
3. Following treatment regimen/Protocols?
__YES ____NO
Awareness
Mode of transmission
Signs &
symptoms(fever,Diarrhea,itching,abd.pain)
treatment
Information about the disease
Yes
No
Prevention
EASTERN SAMAR STATE UNIVERSITY- COLLEGE OF NURSING CLASS 2018- BATCH JADE
SERIAL NO.________________
Page 3 of 4
Republic of the Philippines
Eastern Samar State University
COLLEGE OF NURSING
Dental Care (D1)
MORBIDITY (D2)
Line
No.
How often does your
family visit a dentist?
Illness Suffered
(2.1)
MORTALITY (D3)
Attended by whom (2.2)
Once a year
Twice a year
When there’s a decay
Never
Others specify:________
Folk
Medicine
Used
(2.3)
__Diabetes
_____ Stroke
__Doctor
__Asthma
__Nurse
__Schistosomiasis
Others
__High blood
____TB
specify;_______________
__Dengue
___Measles
__Fever Others:__________
Pregnancy Record (D7)
Family Planning (D8)
Line No.
Obste Prenatal
Delivered
Natural:
Artificial:
Surgical:
tric
w/
by whom
Scori
supervisi
Vasectomy
ng
on
patch
ligation
G__
___YES
Legend:
OTHERS
P__
1-doctor
SPECIFY:_
(T__
___NO
2- nurse
______
A___
3-midwife
OTHERS
Others
A___
4-BHW
SPECIFY:__________
specify;_____
L___
5-Hilot
M)__
Anthropometric Measurement (D6)
Line No
Height
Weight
BMI
Indication
(meters)
(Kgs)
Legend: 1 – Obese
2- Normal
3- Underweight
Manner of
Treatment
Cause
Year
death
(3.1)
of
Age
(3.2)
Cause
of
Death
(3.3)
Doctor
Nurse
Tambalan
Others specify:______
Heart disease
Kidney failure
Heart attack
Lung Cancer
Others:______
Line
No.
L
E
G
E
N
D
Attendance at Death
(3.4)
E. NUTRITIONAL STATUS
Type/Feeding Pattern Manners (E3)
(E2)
1- Powdered Milk
2- Evaporated
Milk
3- Condensed
Milk
4- Infant formula
5- Breastfeed
6other________
1- mixed feed
2-bottle feed
3-breastfeeding
4-other
specify_________
Supplements (E4)
1- am
2- smash potato
3-banana & rice
4- Vegetable & rice
5-Porridge
6-other_________
4-Overweight
EASTERN SAMAR STATE UNIVERSITY- COLLEGE OF NURSING CLASS 2018- BATCH JADE
SERIAL NO.________________
Page 4 of 4