FAMILY FOLDER

SARASWATI COLLAGE NURSING,

UDAIPUR [RAJ]

NAME OF STUDENT - ………………………………………………………

CLASS - …………………………………………..………….

PLACE - …………………………………………..………….

DATE - …………………………………………..………….

……………………. ……...................

SING OF SUPERVISOR SING OF H.O.D

 FAMILY FOLDER

FAMILY FOLDER NO - ………………….

1. NAME OF THE HEAD OF FAMILY -……..

2. AGE -………………. SEX -……….

3. HOUSE NO -…..

4. NAME OF THE FAMILY MEMBER THEIR RELATIONSHIP WITH HEAD OF

FAMILY

RELATIONSHIP
S.N. NAME AGE SEX
WITH H.O.D.

5. DEMOGRAPHIC STATUS- (AGE WISE DISTRIBUTION)

S.N. CATEGORY SEX NUMBER

1 INFANT
2 TODDLER
3 PRE-SCHOOL
4 SCHOOL
5 ADOLESCENT
6 ADULT
7 OLDER

6. FAMILY CHARACTERISTICS - L.I.G. M.I.G. H.I.G.

7. TYPE OF FAMILY - NUCIFAR JOINT EXTENDED

8. RELIGION - …………………… CASTE - ……………………………………..

9. OCCUPATION - …………………………………………………..
 FAMILY FOLDER

10. EDUCATION

S.N. NAME NOT PRIMARY MIDDLE SECONDARY HIGH GRADUATE/POST

LITERATE SCHOOL SCHOOL SCHOOL SCHOOL GRADUATE

11. ECONOMIC CONDITION –

I- TOTAL MONTHLY INCOME - ………………….
TOTAL MONTHLY EXPENDITURE - …………………………….
II- PER CAPITA INCOME - ……………………………..
12. HOUSE DETAILS

a) Type Pakka Semi Pakka Kaccha

b) No. of Room 1 Room 2 Room More than 2 room
c) Kitchen Separate Corner Varanda
d) Bathroom Separate Corner Room Open
e) Latrine Water seal Public Latrine Open defecation
f) Light Electricity Gas Lamp Oil Lamp
g) Natural Lighting Adequate Inadequate
h) Ventilation Adequate Inadequate No ventilation
i) Water Supply Tap/Hand pump Well Open Tank
Other
j) Drainage Water closet Open Soak Pit
k) Furl Used Electricity Gas Fire wood
Kerosene Charcoal If other specify

13. PERSONAL HYGIENE – Maintained / Not Maintained

14. NUTRITIONAL STATUS
I- FOOD HABIT – Vegetarian / Non-vegetarian
II- DIET -0 High caloric / Moderate Caloric / Low Caloric
III- GENERAL NUTRITIONAL STATUS OF FAMILY - …………….
 FAMILY FOLDER

15. IMMUNIZATIONAL STATUS (CHILDREN UNDER 5 YEAR OF AGE)

S.N. VACCINE COMPLETE IN COMPLETE ON PROCESS

0-1 Y 1-3 Y 3-5 Y 0-1 Y 1-3 Y 3-5 Y 0-1 Y 1-3 Y 3-5 Y

1. BCG
2 O.P. 1
V 2
3
3 D.P. 1
T 2
3
4 MEASLES
5 HEPATITIS B

6 VITAMIN A
7 ANY OTHER

16. IS ANY WOMEN PREGNANT OR HAS RECENT PREGNANCY- YES / NO

(IF YES, MENTION FOLLOWING DETAILS)

S.N. NAME ABTENATAL ASPECT POSTNATAL ASPECT

REGISTRATION IMMUNIZATION DELIVERY CONDITION
REGISTERED UNREGISTERED COMPLETE INCOMPLETE ON HOME CENTRE
PROCESS
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17. FAMILY PLANNING SERVICES –

S.N. NAME OF USING PERMANENT TEMPORARY

ELIGIBLE CONTRACEPTIVE
COUPLE METHOD
TUBECTOMY VASECTOMY

18. VITAL STATISTICS –

I- BIRTH

S.N. NAME AGE SEX REMARK

II- DEATH

S.N. NAME AGE SEX REMARK

III- MARRIAGE

S.N. NAME AGE DATE OF MARRIAGE

BRIDE BRIDE GROOM