Identification and Family data/ General identifications:
Family details:
Name of the village/ city-
Nearest health center-
Type of the family:
Nuclear/ Joint/ 3 Generation
Composition of the family:
Total number of family members=
Head of the family (name):
Address & area map:
(Write the complete address & draw the area map from the main road to the nearest PHC/ Sub center and the house where the case has to be taken)
Elevation of the house:
(Draw frontal view of the house)
Cross-sectional plan of the house:
(Draw cross-section of the house)
Habituated since: ____________(duration in years/ months)
Migrated....yes/ no
If migrated then
Migration details:
Migrated from:________________(name of the place)
Duration:__________
Reson for migration:_______________________
Nationality: Indian/ ___________________
Family structure:
Socioeconomic status:
According to ____________(Name of the classification)
Per capita monthly income
= Total family income/ Total no. of family members
Above/ Below poverty line
Having APL/ BPL card: Yes/ No
Colour of the card:_________________
Approximate expenditure of the family per month:
Food: Rs__________
Housing: Rs_____________
Clothing:Rs____________
Education:Rs_______________
Ceremonies:Rs_________
Medical care:Rs_______________
Recreation:Rs_____________
Others:Rs______________
Total expenditure: Rs___________________
Savings: Total monthly income- Total monthly expenditure
=_____________(Increasing/ Decreasing/ Satisfactory)
Debt: Yes/ No (Increasing/ Decreasing/ Satisfactory)
Privileges:
Yes/ No
Financial benefits from the government: Yes/ No
Old age/ Handicap/ Widow pension: Yes/ No
Health insurance benefits from the government: Yes/ No
If yes list them____________________
______________________________________________
Utilization of social & health services: Yes/ No
If yes list them___________
______________________________________________
Vital events in the family:
Family health study:
Health problems in other family members: Yes/ No
Immunization status of the family members: ___________
Housing and Environment:
House:
Area: Urban/ Rural/ Slum
Tenure: Own/ Rented
Type of the house: Pucca/ Katchcha/ Semi-pucca
Set back: Adequate/ Inadequate/ Nill
Attachments: Side to side/ Back to back/ Both/ Nill
Roof: Concrete & cement/ RCC/ Tile/ Zinc sheet/ Thatched/ Others
Floor: Cement/ Mud/ Stone/ Others
Construction safety: Yes/ No
Spatial space (height): Sufficient/ Insufficient
Living space (rooms): Adequate/ Inadequate
Overcrowding: Present/ Absent
Doors & window space: Sufficient/ Insufficient
Ventilation: Adequate/ Inadequate
Cross-ventilation: Present/ Absent
Natural light: Adequate/ Inadequate
Artificial light: Adequate/ Inadequate
Lightening (with artificial light): Adequate/ Inadequate
Dampness: Present/ Absent
Appliances: Refrizator/ Washing machine/ TV/ Others_______
Bathroom: Separate/ not separate
Bathroom drainage: Hygienic/ Non-hygienic
Mosquito breeding: Yes/ No
Fly breeding: Yes/ No
Potential mosquito breeding areas: Present/ Absent
Potential fly breeding areas: Present/ Absent
Cattle: Present/ Absent
If yes distance of cattleshed from the living room________m
Cleanliness of the premises: Clean/ Unclean
Surroundings of the house: Water collection-Yes/ No, Children excreta-Yes/ No, Dogs-Yes/ No, Poultry-Yes/ No, Pig-Yes/ No, Rats-Yes/ No
Inside the house: Rodents-Yes/ No, Cockroaches-Yes/ No, Snakes-Yes/ No, Scorpion-Yes/ No, Pets-Yes/ No, Poultry-Yes/ No, Cattle-Yes/ No
Kitchen:
Situated: Separately/ With a living room
Cleanliness: Clean/ Unclean
Space: Spacious/ Congested
Floor-type: Katchcha/ Pucca
Light: Adequate/ Inadequate
Ventilation: Adequate/ Inadequate
Storage of cooked food: Outside/ Refrigerator/ Closed/ Open
Storage of uncooked food: In jute bags/ Plastic containers/ Aluminum containers/ Mud-made containers/ Earthen pots
Fuel used: LPG/ Biogas/ Coal/ Wood/ Cowdung cakes
Chulha used: Smokeless/ Smoke letting
Smoke outlet/ Exhaust: Present/ Absent
Drainage: Open/ Closed
Facilities for washing utentils: Present/ Absent/ Inside/ Outside
Water supply:
Source of drinking water: Public/ Private/ Well/ River/ Borewell
Supply: Intermittent/ Continuous
Source of water for other purposes: Same/ Other_________
Storage of drinking water: Overhead tanks/ Buckets/ Bottles/ Others
The distance of walk to get water (If needed to carry): _________
Method of drawing out water for drinking from the container: Hygienic/ Unhygienic
Purification of water: Done/ Not done
If done, then method of purification: Boiling/ Filtration/ Chlorination
Evidence of mosquito breeding in stored water: Yes/ No
About of water used per day by the family:_________Litres
Refuse/ Waste disposal:
Storage inside the house: Hygienic/ Unhygienic
Disposal outside the house: Hygienic/ Unhygienic
Frequency of disposal: Daily/ Weekly/ __________
Latrine:
Present/ Absent/ Own/ Shared/ Community type
Space: Adequate/ Inadequate
Water availability: Present/ Absent
Type of latrine: RCC/ Borehole/ _____________
Toilet maintenance: Hygienic/ Unhygienic
Wastewater disposal: Hygienic/ Unhygienic
Lightening: Adequate/ Inadequate
Social/ Psychosocial environment:
Any cause of psychosocial stress: Yes/ No
The family generally accepted by the community: Yes/ No
Relation with family members & neighbours: Good/ Not good
Personal hygiene of the family members: Satisfactory/ Not satisfactory.
Custom & health practices:
System of marriage_______________
Usual age of marriage for boys____________years
Usual age of marriage for girls__________years
Average expenditure on marriage___________
Dowry prevalent in society: Yes/ No
Any other significant custom___________
Maternal & child health practices:
Pregnancy: Special diet- Yes/ No, physical activity-Yes/ No, ANC -Yes/ No, Any other significant practicpractice ________
Lactation: Special diet- Yes/ No, physical activity-Yes/ No, ANC -Yes/ No, Any other significant practicpractice ________
Child-rearing practices:
Special practices such as oil bath & Kajal application-Yes/ No
Usual time of commencement of breastfeeding___________
Colostrum is given- Yes/ No
Artificial milk has given during breastfeeding-Yes/ No
The usual age for starting of weaning_______months
The usual weaning foods______________________
Attitude towards childhood immunization: __________
Health practices:
System of medicine preferred: Allopathy/ Ayurved/ Homeopathy/ __________________
Medicines taken from_________________________
Knowledge, attitude & practices towards common illnesses: _______________________________________________
KAP regarding contraception:
The knowledge that births can be planned-Yes/ No
If yes then what are the methods known-__________
Do they know from where to avail services for contraception-Yes/ No
Which method___________________________
If no, then why not_____________________________
No of eligible couples in the family___________
Dietary assessment of the family:
- https://www.nin.res.in/downloads/DietaryGuidelinesforNINwebsite.pdf
- https://www.researchgate.net/figure/A-sketch-map-left-with-its-corresponding-metric-map-generated-from-OpenStreetMap_fig1_262372321 photo credit
- https://in.pinterest.com/pin/395964992229178838/ photo credit
- https://cadbull.com/detail/153045/AutoCAD-House-Building-Cross-Section-Drawing-DWG-File photo credit
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