3. A. Head of the Family
Name : L. L
Age : 54 y.o
Date of Birth : March 23, 1961
Civil Status : Married
Religion : Roman Catholic
Occupation : Teacher
Educational Attainment : College Degree
Monthly Income : Php 24,000
Family Case
4. Name Relation
to Head
Age Civil
Status
Education
al
Attainmen
t
Occupati
on
Residenc
e
Lustria Wife 52 Married College Housewife Bata
Lucio III Son 25 Single College Call
Center
Agent
Bata
Ruby
Jade
Daughter 24 Single College Call
Center
Agent
Bata
Kimberl
y
Daughter 20 Single Undergrad
uate
Student Bata
Family Case
5. I. ECONOMIC STATUS
Income : >15,000 /month
Source : Employment
II. HOUSE AND LOT OWNERSHIP AND ENVIRONMENTAL
SANITATION
A. Housing : Rent
B. Water Supply :
1. Source :Spring
2. Distance Of Water Source From Potential Source Of Pollution :
50 feet
3. Methods For Water Transport: Pail with cover
4. Storage : Water Tank with cover
5. Methods Of Making Water Safe For Drinking : Filtration
Family Case
6. 6. Use of drinking glasses : Individual
C. Toilet Facilities
1. Toilet Type : Septic Tank (Flush type)
2. Cleanliness : Good
D. Garbage Disposal
Dump in Isolated Place
E. Premises
1. General Condition : Very Clean
2. Drainage : Blind
Family Case
7. Family Planning Methods Used: NO CONTACT
Name of Child
Place of
Delivery
Complication Immunization
Lucio III CLMMRH None FIC
Ruby Jade CLMMRH None FIC
Kimberly CLMMRH None FIC
Family Case
8. A. FAMILY HYGIENE
Bathing
Brushing of Teeth
Washing Hands Before Eating
B. EATING HABITS
Eating with utensils; Serving Spoon
C. STORAGE FACILITIES
Refrigerator
Family Case
9.
10. Almost
Always(2)
Some of the
Time(1)
Hardly Ever (0)
A
I am satisfied that I can turn
to my family for help when
something is troubling me.
√
P
I am satisfied with the way
my family talks over things
with me and shares
problems with me.
√
G
I am satisfied that my family
accepts and supports my
wishes to take on new
activities and directions.
√
A
I am satisfied with the way
my family expresses
affection and responds to
my emotion.
√
R
I am satisfied with the way
my family and I share time
together.
√