Family Health Survey Proforma PDF

RAJKUMARI AMRIT KAUR COLLEGE OF NURSING, LAJPAT NAGAR, NEW DELHI-24 RURAL FIELD TEACHING CENTRE (R.F.T.C) CHHAWLA Field Teaching Programme for II year B.Sc (Hons.) Nursing students Serial No:____________________ Date of investigation:_________________...

RAJKUMARI AMRIT KAUR COLLEGE OF NURSING, LAJPAT NAGAR, NEW DELHI-24 RURAL FIELD TEACHING CENTRE (R.F.T.C) CHHAWLA Field Teaching Programme for II year B.Sc (Hons.) Nursing students Serial No:____________________ Date of investigation:__________________ 1.FAMILY CHARACTERISTICS: 1.1 Name of the area/village:_________________________________________ 1.2 Name of the head of the family:-___________________________________ 1.3 Address:-_____________________________________________________ 1.4 Type of family:- Joint_________Nuclear:______________any other______ 1.4 Total number of family members:-_________________________________ 1.5 Religion:-___________________(Hindu/Muslim/Sikh/Christian, any other) 1.6 Caste:-____________________________(Brahman/Jaat/Harijan/any other) 1.7 Food preference: vegetarian: _non vegetarian:_egg vegetarian___mixed___ 2. FAMILY COMPOSITION S.No Name of the Relationship Age Sex Educ Occup Income Marital Immunizat family with HOF ation ation status ion status members C. HOUSEHOLD CHARACTERISTICS 1. General appearance: clean___________dirty_________ 2. Type of house: Pucca______Kuccha_______ (own house/ rented house) 3. Number of rooms: ______________ (adequate/inadequate) 4. Number of person per room: ___ Overcrowding: Present_____Not present 5. Ventilation: Adequate________Inadequate:_____________ (Check for cross ventilation) 6. Electricity: Yes_________ No__________ 7. Source of light: Natural_________ Artificial:________Both:__________ 8. Source of water supply: - Community supply/Household supply/ Tap/Hand Handpump/Well. 9. Place for washing/bathing__________ (separate/ any other (specify) 10. Kitchen facility:-……………separate, Verandha/one corner any other Cleanliness…………………………clean/Moderately clean / dirty Chula……………………………. Gas/ electric/ oil mode/ coal /any other 11. Excreta disposal:- Household latrine__________ Community latrine____________Open defecation___________ 12. Spillage water disposal:- Soakage pit________Open drainage_____ Closed drainage_________ mosquito breeding site present 13. Refuse disposal: Dustbin(MCD facility) ______ Field disposal_____ Burning_____ 14. Community awareness______________ (yes/no). Are you aware of the health facilities near you ? How often do you use these facilities ? Are these facilities useful to you ? D. MODE OF TRANSPORT Bus service Adequate/ Not adequate Own vehicle ( If any, specify) Others E. MEANS OF COMMUNICATION Radio yes/ No TV yes/ No Internet yes/ No Newspaper yes/ No Magazine yes/ No Smart phones yes/No Landline phones yes/No F. SOCIO-ECONOMIC STATUS 1. Main occupation of the family: ______________________ 2. No. of earning members________________________ 3. Source of the income: ___________________________ Total income of family: __________ Per capita income: ____________ (low/middle/high) PET ANIMAL AND POULTRY: _____________ Pet animal kept in premises__________(yes/no) Pet animal: Dog/Cow/Goat/Buffalo/any other________________ Personal Habits: ------Tobacco__________- Smoking___________-- Alcohol________ Any Drugs Sedentary life style(No physical activity, long periods of sitting/lying down etc.) Yes/No If any habit of Walking/Running/Yoga/Gym/others Yes/No Remarks : ___________________ G. NUTRITION AND FOOD HYGIENE General nutritional assessment 1. Food preference: vegetarian:__non vegetarian:_egg vegetarian___ mixed___ 2. Menu for a day: ____________ 3. Staple/ common food of house: ________________ 4. Number of meals per day: _____________________ MORBIDITY INFORMATION S.No Name Age Sex Education Nature of illness Treatment HEALTH STATUS OF FAMILY: -------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------- HEALTH PROBLEMS FELT BY FAMILY -------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------- HEALTH PROBLEMS FELT BY INVESTIGATOR -------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------