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    Familyfolderformat 130426041957 Phpapp01 1 4

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    atikul Islam
    This document contains a family profile data collection form for community health nursing. It collects information on [1] the identification of the head of household and family type, [2] the housing conditions, [3] family composition including name, age, sex, education and health status of each member, [4] transportation and communication facilities, [5] languages known, [6] nutritional patterns and status of family members, [7] record of illness in the family, [8] pregnant women and their prenatal care, [9] eligible couples and their family planning methods, and [10] where the family seeks treatment when sick.

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    Familyfolderformat 130426041957 Phpapp01 1 4

    Uploaded by

    atikul Islam
    20 views4 pages
    This document contains a family profile data collection form for community health nursing. It collects information on [1] the identification of the head of household and family type, [2] the housing conditions, [3] family composition including name, age, sex, education and health status of each member, [4] transportation and communication facilities, [5] languages known, [6] nutritional patterns and status of family members, [7] record of illness in the family, [8] pregnant women and their prenatal care, [9] eligible couples and their family planning methods, and [10] where the family seeks treatment when sick.

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    family discription

    Original Title

    familyfolderformat-130426041957-phpapp01-1-4 (1)

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    This document contains a family profile data collection form for community health nursing. It collects information on [1] the identification of the head of household and family type, [2] the housing conditions, [3] family composition including name, age, sex, education and health status of each member, [4] transportation and communication facilities, [5] languages known, [6] nutritional patterns and status of family members, [7] record of illness in the family, [8] pregnant women and their prenatal care, [9] eligible couples and their family planning methods, and [10] where the family seeks treatment when sick.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    20 views4 pages

    Familyfolderformat 130426041957 Phpapp01 1 4

    Uploaded by

    atikul Islam
    This document contains a family profile data collection form for community health nursing. It collects information on [1] the identification of the head of household and family type, [2] the housing conditions, [3] family composition including name, age, sex, education and health status of each member, [4] transportation and communication facilities, [5] languages known, [6] nutritional patterns and status of family members, [7] record of illness in the family, [8] pregnant women and their prenatal care, [9] eligible couples and their family planning methods, and [10] where the family seeks treatment when sick.

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    of 4

    www.drjayeshpatidar.blogspot.

    com
    1

    COMMUNITY HEALTH NURSING

    (NO. _____)

    NAME OF STUDENTS :- _________________________________

    CLASS :-__________________________________

    DATE FROM :-________________ TO ______________


    www.drjayeshpatidar.blogspot.com

    FAMILY PROFILE DATA

    Primary Health Centre: ________________________________


    Sub Centre : _______________________________
    Name of the Village: _________________________________

    1. IDENTIFICATION INFORMATION

    Head of family – Name:__________________________________________

    Occupation : ___________________________________________________

    Address_________________________________________________________________

    ________________________________________________________________________

    Type of family: Nuclear Joint

    Religion: Hindu Muslim Christian Any other

    2. HOUSING CONDITION

    1.Type of House: Completed Independent Tileld Sheeted


    Hut Owned Rented

    2. Rooms : Number - Adequate Inadequate

    3. Kitchen : Separate Attached to room.

    4. Fuel Used : Gas Kerosene Fire Wood Electricity

    5. Ventilation : Adequate Inadequate

    6. Bath Room : Separate Common

    7. Lighting : Electricity Oil Lamp

    8. Drainage : Open Close

    9. Water Supply : Tap/Hand Pump Well Chlorined. - Yes/No Open Tank Chlorinated

    10 Toilet : Own Public Open field

    11 Disposal of Waste:Composing Burning Buying

    12 Cattle Shed : Separate Within the House


    www.drjayeshpatidar.blogspot.com

    3. FAMILY COMPOSITION

    S Name Relationship Age Sex Education Occupation Health Immun


    N With Head Status ization
    of the Family Status
    1

    4. TRASPORT AND COMMUNICATION FACILITIES B. Communication Media

    A. Transport Yes No
    Own Yes/No Telephone

    Tractor Tempo Wheeler Television

    Bus City Bus RSRTC Private Radio

    Autos Taxies Train Newspaper/Magazines


    Post & Telegraph

    5. LANGUAGES KNOWN

    Marwadi Mewadi Gujrati


    English Hindi Any Other

    6. A)NUTRITIONAL PATTERN

    Vegetarian Non Vegetarian


    Staple Food : Rice Wheat Ragi Mixed
    Vegetables : Grown Purchased Quantity used per day: ……kg
    Milk : Quantity used per day ………litres
    Non Vegetarian Dish: Specify…………………. How often ……………
    www.drjayeshpatidar.blogspot.com

    B) NUTRITIONAL STATUS OF FAMILY MEMBERS

    Name of the Member Nourished/Under Nourished Malnutrition

    7. RECORD OF ILLNESS

    Name of the Member Age Illness Duration Main Investigation Treatment


    Characteristics done

    7. PREGNANT WOMAN

    Name Age Gravida No. of Children Whether Registered in Receiving Iron


    & Para Living Hospital/Nursing Home and Folio Acid

    9. ELIGIBLE COUPLES

    Name Age Family Planning Method Not interested willing to use


    Adopted in Family Planning Family Planning method

    10. IN CASE OF SICKNESS, WHERE DO YOU GO FOR TREATMENT?

    Name/Primary Health Centre Private Nursing Home

    Sub Centre Indigenous Doctor/Dai

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