FAMILY HEALTH SURVEY 1.GENERAL INFORMATION: 1. Name of the community 2, Name of the CHC/PHC 3. Name of head of the Family 4, House No. 5. Type of Family 6, Religion 7. Income per year 8. Land Holding 9. Crops Grown 10. Live Stock 11. Occupation 12, Mother Tongue 13, Language Known “Rural: | Urban] Nuclear: [ ] Joint : [ J Caste: Sub Caste:. iRs, Bot, Present: [ ] Absent :[ ]IFAMILY COMPOSITION: i Income 5 Occupation iy, | Name of the family | Relation ‘Age [Sex | Marital Education) Nod Member with head of | in years Status aT FamilyIII, HOUSING: 1. Type ofHouse : Pacca :[ ] Semi Pacca :{ ] Kuncha :[ } 2. Rooms : Adequate :[ ] Inadequate :[ ] No. 01 3. Occupancy : Owner a Tenant wd 4, Ventilation 1 Adequate :[ ] Inadequate :[ ] 5. Lighting : Natural : Adequate[ ] Artificial : Adequate[ ] 6. Water Supply : Tap water :[ ] Hand Pump :[ J Open Well: [ J lakes :[ ] River :0] Ponds :[ ] 7. Water Storage : Hygienic :[ ] Unhyglenic :[ ] 8. Kitchen : Separate :[ ] Attached :[ ] 9. Fuel used for: LPG 201 Kerosene :[ ] Fire Wood: [ ] Cooking 10. Type of Chula: Traditional :[ ] Smokeless :[ ] 11. Bathrooms: Separate :[ ] Attached =: [ ] 12. Drainage : Open fea Closed :f] IV. ENVIRONMENTAL FACTORS: 1. Sewage Disposal: Soakage pit: { ] Kitchen garden: [ ] 2. Refuse Disposal : Dumping :[ ]Fleld :[ ] Burning: [ ] Composting: { ] 3. Environment :House : Clean:[ ] Unclean:[ ] Surrounding: Clean: [ ] Unclean:[ ] 4, Lavatory Household latrines [ ] Openairdefecation:[ ] V) DOMESTIC ANIMALS AND PESTS: 1. Pet animals / poultry: Dog tL ] Cat: [ ]Goats:[ ]Sheeps:[ ] 2. Cattle Shed : Location : Separate: [ ] Inside the house: [ ] : Flooring: Previous: { ] Imprevious: [ ] 3. Domestic pests : Files: ] Mosquito: ] Bugs: { ] Rodents: { ]NUTRITION: i, Dietary pattern : Vegetarian: [ ] Mixed :[ ] 2. Nutritional Status + Poor :f) Moderate: [ ]Good:[ ] VII) Transport Facilities: Private if] Govt. :[ ] Own: [ j VII) COMMUNICATION: 1. Telephone :[ ] Television :[ ] Radio:[ ] Newspaper/Magazines :[ ]Post:[ ] TX) HEALTH SERVICE FACILITIES: 1, Access to health care facilities rYes:[ ] No.:[ ] 2. Sources of health care providers : Govt.:[ J] Private: [ ] 3. Frequency of visit 5 __/ year 4. Appropriate referral facilities rYes:[ ] No.:[ ] X) FAMILY LIFESTYLE: 1. Who has the decision making authority: HOF :{ J Individual :{ J 2. Attitude of family towards health : Poor :L ] Good it] 3. Response of the family stress and strain: Poor :[ ] Good :t] 4. Sources of Social support :Friends :[ ] Neighbors :[ ] 5. Relationship with religious groups : Poor :[ ] Good :f] 6. Community possess the resources to family: Yes :{ ] No {] 7. Use of these resources by the family : Poor [£ ] Good eel 8. Recreational facilities : Present :[ ] Absent t 9. Health Hazards : Present :[ ] Absent :f] 10. Sleep and rest : Adequate :[ ] Inadequate : C Yes iT ] No <0) fi i Present :[ ] Absent 11. Exercise 12, Smoking and drinking habits 13. Drug users and abusers : Present :[ ] Absent :t]xt, Tramun Mt. HISTORY OF PREGNANT WOMEN: ' ization tment = Name lo. Age | Gravidal para Tre Xil) IMMUNIZATION STATUS OF CHILDREN: ‘Any other / Hbs no BCG | Pentavatent OPV injectable | MINN] Measles | Hepatitis ‘Ag, Typhold, Hl, Polio ® ete. Vaccine 2]2[3[8lola|2|3 [611 12 Tz 2 [epi XIII) FAMILY PLANNING STATUS: 1. No. of living children + Males:{ Females: tl 2. Age of the last child : 3. Eligible couple for family planning Yes/No Number: {1 4. Target couple Yes/No 5. Family planning methods adopted Yes/No \f Yes, mention Yes/No 6. Infertility in the family— weed Jo 832. \ ~s owen “ON 1s speed "Zz, sui yo 080, owen as sua -T RIVA AN3S3Ud 3HLLNISNGAS AIA (AD“~~ 3. Marriages: ‘Name of the Couples«Problems identified : «Needs of the Family : a a Signature of the Student Signature of the Supervisor 5