A survey form to determine the demographic profile of family of malnourished children.

1. DEMOGRAPHIC PROFILE OF MALNOURISHED CHILDREN SURVEY FORM
Part 1 – Profile of Malnourished Child: Please write your answer on the blank provided.
Age:__________ Gender:_______
Weight (In kilogram):______________ Height:_______
Part 2 – Family Profile:
Instructions: Please read and answer every question item by putting a CHECK (√) mark on the
option given.
1.Who works in your family?
( ) Husband. If (Checked) please specify occupation __________________________
( ) Wife. If (Checked) please specify occupation _____________________________
( ) other relatives. (Checked) Please specify occupation_________________
2. How much is your monthly income?
( ) Php 20,000 & above ( ) Php 5,000-9,999
( ) Php 15,000 – 19,999 ( ) Php 2,500-4,999
( ) Php 10,000-14,999 ( ) Below Php 2,500 below
3. Highest Educational Attainment:
3.1 Mother _________________________________________
3.2 Father _________________________________________
3.3 Other Relative (Provider)__________________________
4. Number of family members: Include parents, children and relatives living together in 1
household.
( )2–3 ( ) 8-9
( ) 4- 5 ( ) 10-11
( ) 6-7 ( ) 12 and above