Choose your age group	□22 years old and below □23-35 years old □36 − 50 years old □51-60 years old □Above 60 years old
Choose your gender	□Male □Female □Other
Choose your income group (by monthly income)	□More than P200,000 □P100,000 - P200,000 □P40,000 - P99,999 □P10,000 - P39,999 □Less than P10,000
Your employment sector	□Agriculture □Industry □Services □Others □Not employed
Your occupation	□Manager □Professional □Technician/associate professional □Clerical support worker □Skilled agricultural, forestry and fishery worker □Plant machine operator / assembler □Others □Not employed
Current Residence (Region)	[Input geographical region]
Current Residence (Barangay, Municipality/City)	[Input residence address]
Name of Healthcare facility you went to / would have gone to	[Input name]
Location of the healthcare facility identified in previous number (Town/city and region)	[Input location]
Was your medical appointment during ECQ/GCQ considered necessary? / Was the (missed/canceled) medical appointment supposed to be necessary?	□Yes, it was an essential medical appointment. □No, it could be deferred to a later date.
What health condition did you have that required a visit to the medical facility?	□Communicable disease (e.g. TB, dengue, etc.) □Non-communicable (e.g. Diabetes, Hypertension, etc.) □Covid-related □I do not wish to disclose □Others
Kindly further specify your health condition (e.g. diabetes, dengue, etc.) You may leave it blank if you prefer not to disclose it.	[Free input]
When did you seek medical attention for this case? Choose all that apply. / When was the appointment supposed to have been made? Choose all that apply. Choose all that apply	□Within 2 months before lockdown □ECQ □GCQ
Pre-Lockdown Mode of Transport (Primary Mode Used in going to/from the healthcare facility)	[Enter mode]
ECQ Mode of Transport (Primary Mode Used in going to/from the healthcare facility)	[Enter mode]
GCQ Mode of Transport (Primary Mode Used in going to/from the healthcare facility)	[Enter mode]