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Household Profile Data Collection Form

The document is a form for collecting household profile information, including details about household members, their relationships, and health insurance status. It includes sections for recording visits across four quarters, along with demographic information such as age, sex, and health risk classification. The form is designed to gather data for both NHTS and non-NHTS households.

Uploaded by

Gleniz Binongcasan Basisihan
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257 views2 pages

Household Profile Data Collection Form

The document is a form for collecting household profile information, including details about household members, their relationships, and health insurance status. It includes sections for recording visits across four quarters, along with demographic information such as age, sex, and health risk classification. The form is designed to gather data for both NHTS and non-NHTS households.

Uploaded by

Gleniz Binongcasan Basisihan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd

Form 1.

HH Profile
1a. First Quarter: Date of Visit 1b. Second Quarter: Date of Visit
-- --
mm - dd - yy mm - d d - yy

2. Name of Respondent:
Last Name First Name

- NHTS- - Non-
3. NHTS Household: ✘
4Ps - NHTS-Non-4Ps NHTS
4 IP ✘ Non- IP
6. Name of household member 7. Relationship of 8. Sex
(Last name, first name, mother’s maiden name) Please provide Member to HH Head M - Male
the names of the members of the household starting from the F - Female
household head followed by spouse, son/daughter (eldest to
youngest), and other members of the household. 1 - Head
2 - Spouse
3 - Son
4 - Daughter
5 - Others, specify
relation
don 1m
asawa
H Profile Household No.: HH101
f Visit 1c. Third Quarter: Date of Visit 1d. Fourth Quarter: Date of Visit
-- --
mm - d d - yy mm - d d - yy

Name Mother’s Maiden Name

5. HH Head PhilHealth Member?


Yes
No ✘
, PhilHealth ID No.
Category_____________________
9. Age 10. Birthday 11. Classification by Age/Health Risk Group 12. Remarks
(mm-dd-yy) N-Newborn (0-28 days) AP-Adolescent-Pregnant (If HH member is
I-Infant (29 days-11 mos old) PP-Post Partum ≥ 21 y/o, ask if
PhilHealth
U-Under-five (1-4 years old) WRA-15 to 49 years old, enrolled and
S-School-Aged Children (5-9) not pregnant and non PP specify
A-Adolescents (10-19 years old) SC-Senior Citizen PhilHealth ID
P-Pregnant PWD-Persons with Disability AB-Adult 20-59 y/o No.)

Second Fourth
First Quarter Third Quarter
Quarter Quarter
74 9/11/1950 S
pills

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