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HomepageSeniors Account

List of Beneficiaries

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I. IDENTIFYING INFORMATION (Pagkilala ng Impormasyon)

First Name *

Middle Name

Last Name *

Barangay *

Date of Birth *

Place of Birth *

Sex *

Civil Status *

II. FAMILY INFORMATION (Impormasyon ng Pamilya)

Spouse First Name

Spouse Middle Name

Spouse Last Name

Spouse Address

Spouse Contact No.

Representative Name

Relationship

Representative Contact No.

Living Arrangement

III. ECONOMIC INFORMATION (Impormasyong Pang-ekonomiya)

Receiving Pension?

Pension Amount

Pension Source

Permanent Income

Income Amount

Income Source

Regular Support

How much

Source

IV. HEALTH INFORMATION (Impormasyon sa Kalusugan)

With Existing Illness

With Disability

FRAILTY QUESTIONS:

1. Do you experience difficulty in doing your ADLs?

2. Are you completely dependent on someone in doing your IADLs?

3. Are you experiencing weight loss, weakness, exhaustion?

V. ASSESSMENT (Pagtatasa)

Recommendation

VI. RECOMMENDATION (Rekomendasyon)

Eligible (Kwalipikado)

Not Eligible (Hindi Kwalipikado)

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BuligLakaySmart Data Driven Welfare and Predictive Assistance System with Geolocation