COMMUNITY HEALTH NURSING

ORMATOFSURYEY OF EAMILIES
. Name of the Arca: Rural Urbun..
2. Name of the Health Centre. **a**

3. Name of the Head of the

tamily..
4. 1ype of Family: 1) Single. 1 ) Jont. ***a******
5. Religion: 1) Hindu . Specity the Subcaste)

******sa********

uy vius...********w******o ** *******************

6. HOUSE CONDITIODN:

p e of House:
Pu

Semi

I) Rooms:
Nu Adc4 )Inadeq
mo

CT

Occupancy:
Te Owne Mo

rent
I) Ventilation:
)
Inadequate

4 No ventintion
V) ighting
E 11) Gas
La
 in) Oil
La
V) Water supply:
ap ) Well

Handpum nn) Open tank

VI) Kitchen:
) Se ii) Conerof ) Varan

roomm

VII) Drainage:
d nade ) No
dra
a ina

IN) Lavatory:
i) Own ectio
Latrine
) Public
latrine

7. FAMILY COMPOSITION:

Name Relationship Age Sex Education Occupationn

NO,
with head

7A. Total Income of Family 7B. Education Status

Number

a) Below 500 a) Not literate

****

b) -1000 b) Primary education

c) 1000-1I500 Middle School

d) 1500-2000 d) High Schoo
 ) 2000-and above e)PUC and above

8.TRANSPORT AND COMMUNICATION MEDIA:

Transport : Media
) Transport 1) Telephone
2) Owns Tempo/Tractor 2) Television
3) Uses B.T.S. /KSRTC 3) Radio
4) Uses Private Buses 4) Newspaper
Magarine
5) Train 5) Post and
Telegraph
Language I Langua
Anown
) Mother Tongue ) Kannada
Read/writespeak
2) Kannada 2) English
Rcad'writespeak
3) Hindi 3)Hindi
Rcad'write'speak
4) Tamil/Telgu 4) Specify Others
Read'write/speak
5) Malayalam/ Marathi
9. DIETARY PATTERN:

FoodPreparation and storage

Foods Available_ Foods used Iraditional deal Unhye
Rice
Ragi
Jawar
Wheat
Vegetable
Frsh
Meat
Eg
Milk and Milk product
Pulses
Tubers

10.STATEMENT OF EXPENDITURE OF THE FAMILY

SI No. Item Amount spernt(Approw) Percentage ofTotal Exp
Food
3
cloth
lothing
Housing (Ren)

4 Medicine
5 Children Education
6 Reereation (Movies ete)
 7 Smoking and/or liquor
Debt
Saving
10 Other (Specity)
11. IS THERE ANY CASE OF FEVER-OF YES, WRITE
NAME, AGE, TREATMENT AND REMARKS)
1. with rnigors
with cough?
w i t h rash?

SINoName Age Disease Treatment Remarks

2
3
12. DOSE ANYONE HAVE SKIN DISEASE (E.G. ITCHING,
PATCH, RASH)?
SINo Narme AE Discase reatment Remarks

13. DOES ANYONE HAVE A COUGH FOR MORE THAN

TWO WEEKS?
SI No. Name Age DISCase reatment KerarkS
2.
3.

14. DOES ANYONE HAVE ANY OTHER ILLNESS?

(CHIKUNGUNYA, HIV, STI, OR ANY OTHER)
SINo. Name Age DIscase Treatment Remark

15. IS ANY woMAN PREGNANT? IF YEA, WRITE THE

FOLLOWING REMARKS
1. Specify gravida
2. has she been registered
IS shegettung

SI No.Name (6) 2
2
3.
 16. HAVE THERE BEEN ANY( WITHIN YEAR -VITAL

STATIC S)
. Birth?
SINo. Name Discase Treatment Remarks

2 Deaths?

SINoName Age Discase Treatment Remarks

8.

3. Mamages

SINo. Name Disease Treatment Remarks

17. ARE THERE ANY CHILDREN BELOW FIVE YEARS

WHO HAVE NOT RECEIVED IMMUNISATION?
(Specifý name, age, reason for not being immunised in remarks)
1. BCG Vaccination
2 DPT Vaccination

3. Poliomyelitis vaccination
4. Measle vaccination
5. Vitamin A solution

SI Name Age Sex17.1 17.2 17.3 174T

No.
 Remarks. s
18. IS THERE ANY ELIGIBLE COUPLE: (IF SO LIST
THEM ON PRIORITY)

S.No. Name Age Sex TPriority) | II(Priority) | PS SS

PS= Primary sterility

SS-Secondary sterility
EM- Early menopuse
1. Using a contraceptivemethod ? if yes, specify
2 Intending to undergo: i. Vasectomy ii Tubal
Ligation
3. Not interested to adopt FP method (state the reason)

*** ********************esssestsssaesnsonsasosseeaen** esasn

**********************************"

19. IS THERE ANY CHILD 5 YEARS IN FAMILY WHO

SHOWS SIGNS OF
1. Kwashiorkor?
MALNUTRITION
2 Marasmus?
3. Vitamin A deficiency?
4. Anacmia

5. Rickets?

S.1.
No. Name Age 19.1 19.2 19.3 194
Remarks.

20.ISTHE SULLAGE WATER BEING DISPoSED OF

IF YES TICK ANYONE/ALL
IYGIENNCALLY?
drain 2.Soakpit
3.Kitchen Giarden
if no, state reasons

*************************************n********e*******"****************
*****

21. IS THE RUBBISH BEING DISPOSED

HYGIENICALLY? IF YES TICKANYONE/ALL
.Composmng 2. Burning 3

Burying
if no, state reason

22. 1S THE EXCRETA BEING DISPOSED OFF

HYGIENICALLY? YES/ NO
if no. state reasons.

23. ARE THE CATTLE AND POULTRY HOUSED

HYGIENICALLY?
1. Separate . Within housc
State reasons

24. IS THERE A WELL OR HAND PUMP?

1. sit maintained in good order? Yes/ NO, if No, state reasons
When was the well chlorinated? (Date) if No, state reasons
for not chlorinating.

25. WHETHER HOUSE IS KEPT CLEAN? Yes / no. lf no.

State reasons.

26. WHEN WAS THE HOUSE LAST SPRAYED? (DATE)

no. State reasons.

27.15 THERE ANY BREEDING PLACE OF INSECTS

AND RODENTS? Yes no.
 28. 1S THERE ANY STRAY DOGS IN THE VICINITY?
Yes/no. If yes write.
Approximate number of dogs

29. IF ANYONE FALLS IL.L WHERE DO voU GET

TREATMESNI?
1. Hospital primary health cenfre
2. sub-cemre primary health unit
3.
Private nuing
Vaid
4. Indigenous doctor/Local Vaidya.

30. ARE OFFICIAL HEALTH AGENCIES SERVICES

ADEQUATE? YEA/ No
if no. state

*****sssa**sanaaaaasaanasant******ese*******************************

Note: In addition to the above) stuaents are expected to obtam following

information by obiervation and other methods.

Description of the community location, tapography, climate history

. etc. Tpe at government no, of schools no of health care agencies

Balwadi or IcDS centres places of worship (eg. Temple) and any

ther relevant information related to healh.

23. List of target couple with details on priority basis

Maintain record of Road to Health Card for knowing the degree of
malnutrition for under 0-5s wherever necessary and use nutitiomal

assessment from promply

4. use problem solving approach construct
good mursing care plan by
using" PRONE lormat taught to you in ecent Commuity Nuning
Process' lectures