III. Health & Medical History 1. Present Illness: Name Chief Complaint Medical Attendance Remarks With Without Tomasa Concepcion Sumasakit ang kasu- kasuan Susan Espiritu Sumasakit ang Tuhod 2. Past Illness: (for the last 5 years) Name Chief Complaint Medical Attendance Remarks With Without Danilo Villapando Seen with small masses on his thyroid Underwent Total Thyroidect omy 3. Immunization Status: No children at home ages below 5 years old 4. Sources of Medical Care a. Health Center Calabash Health Center b. Hospital University of Santo Tomas Hospital c. Private Physician Dr. Melchor Chan; Cardilogist: Dr. Francis Purino; Endo: Dr. Elaine Cunanan 5. Nutritional Assessment No children being breastfed nor formula-fed. IV. Environmental Factors A. Home 1. Ownership ( ) owned ( ) rented ( ) rent-free 2. Construction materials used: ( ) Light ( ) Mixed ( ) Strong 3. State of Repair

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III. Health & Medical History1. Present Illness:NameChief ComplaintMedical AttendanceRemarks

WithWithout

Tomasa ConcepcionSumasakit ang kasu-kasuan

Susan EspirituSumasakit ang Tuhod

2. Past Illness: (for the last 5 years)NameChief ComplaintMedical AttendanceRemarks

WithWithout

Danilo VillapandoSeen with small masses on his thyroidUnderwent Total Thyroidectomy

3. Immunization Status:No children at home ages below 5 years old

4. Sources of Medical Carea. Health Center Calabash Health Centerb. Hospital University of Santo Tomas Hospitalc. Private Physician Dr. Melchor Chan; Cardilogist: Dr. Francis Purino; Endo: Dr. Elaine Cunanan5. Nutritional AssessmentNo children being breastfed nor formula-fed.

IV. Environmental FactorsA. Home1. Ownership( ) owned( ) rented( ) rent-free2. Construction materials used:( ) Light( ) Mixed( ) Strong3. State of Repair( ) good( ) fair( ) dilapidated4. Overcrowding( ) with( ) without5. Privacy( ) with( ) without6. Lighting( ) with electrivity( ) without electricity7. Venitlation( ) satisfactory( ) fair( ) poor

Calculations:Total Window Opening:Length: 1.4 mWidth: 1.1 m 1.4x 3 windows 4.2

Total Space Area Length: 8 mWidth: 6 m 48 x 1 floor 48 TSRAdult: 10 y/o and above = 3 sqm3 persons x 3 sqm = 9 TSA > TSR

B. Environment1. Drinking Supplya. Source:( ) MWSS( ) Open Dug well( ) Artesian( ) Others, Specify: _________b. Ownership:( ) owned( ) shared

2. Toilet Facilitya. Type of Toilet( ) none( ) pail system( ) overhung latrine( ) Antipolo( ) open pit privy( ) water-sealed latrine( ) closed pit privy( ) flush type( ) bored-hole latrine( ) other, specify: _________Distance from house: 3 metersb. Ownership:( ) owned( ) sharedc. Sanitary Condition( ) Sanitary( ) unsanitary

3. Refuse Disposal( ) hog feeding( ) open burning( ) open dumping( ) garbage collection( ) burial in pit( ) other, specify: _________( ) composting

4. Drainage System( ) hog feeding( ) open burning( ) none

5. Domestic AnimalsKindNumberWith PensWithout Pens

Cat202

6. Insect & Vermin Controla. Home( ) mechanical( ) chemical( ) biological( ) others, specify, ________