Family Folder

Family folder No………………

1. Identification Information
 House No.: ………………………………………………………………………………………………………….............................
 Block /sector/ ward No. name of street: ………………………………………………………….........................................................
 Village /city: ……………………………………………………….District: ……………………….State :…………………………
 Name of the head of the Family: …………………………………………………………………………….......................................
(In block letters)
 Religion : …………………………………………....Caste :……………………………………........................................................
(if applicable)
2. Family Composition and Characteristics
(i) Description of family members

S. Name of the Member Age Sex Education level + Occupation Relationship with head of Remark Special status Single /
No. Family widow/adopted etc.)
1.
2.
3.
4.
5.
6.

+ Pri. (Primary). Midd (Middle), Sec (Secondary). Sr.Sec.(Senior secondary) Gr.(Graduate). PG (Post Gradate)
(ii) Type of family: ……………………………………………………………………………………………………...............
(Nuclear /joint /broken)
(iii) Economic Status of the Family
 Number of earning members: ………………………………………………………………………………………………
 Total income of family: ……………………………………................................................................................................
 System of family budget (Yes /No): …………………………………………………………….........................................
 If yes, description of expenditure and savings: ………………………………………………............................................
 Other financial resources: ……………………………………………………………………………………………….....
 Head Items Amount % of budget
- -
Food
- -
Health
- -
Clothing
Expenditure - -
Education
- -
Housing ( Rent)
- -
……………….
- -
For future
Social works / tasks
Saving
For unexpected - -
expenditure

(iv) Means of communication

 Language of the family

- Mother tongue/ regional:……………………………………………………………………………………………………………..

- State:…………………………………………………………………………………………………………………………………
-National :…………………………………-any other (specify)……………………………………………………………………..
 Communication facilities available : (i)…………………………………………..(ii) …………………………………...................
(Newspaper /Magazine (iii)..………………………………………..(iv)…………………………………………......
Internet/Fax/ Telegraph/
Phone (Mobile) etc.

(v) Transportation facilities: (i) ………………………………………… (ii) ………………………………....................

(On foot / cycle /bullock cart/ (iii)………………………………………….(iv)……………………………………………
Scooter/ car/public transport/
Private vehicle/ rail etc.)
(vi) Nutritional status :……………………………………………………………………………………………………………………
(Vegetarian/Non vegetarian)
 Eating pattern : …………………………………………………………………………………………………………………..
 Selection and preparation : ………………………………………………………………………………………………………
 Staple foods of the family (specify) : ……………………………………………………………………………………………
3. Environmental Assessment
(i) Housing
 Built : ………………………………………………………………………………………………………………………………
(Slum/ pucca /kuccha/ wellbuilt up)
 Number of rooms in the house :……………………………………………………………………………………………………
 Average size of rooms :……………………………………………………………………………………………………………
 Ventilation (adequate/ inadequate) : ………………………………………………………………………………………………
 Total area of house:…………………………………………………………………(sq. feet)……………………………………
(ii) Source of light :………………………………………………………………………………………….............................................
(Electricity / gas lamp /oil lamp0
(iii) Water supply:…………………………………………………………………………………………..............................................
(Public supply system/
Tube well /colony supply/well /thank/ hand pump /manual on head etc.)
(iv) Kitchen
 Place :
(Separate /varanda /corner of room/open)
 Sources of fuel:………………………………………………………………………………………………………………………
(LPG/Kerosene oil/ Electric
Charcoal /cowdung cakes ( kande)/smokeless Chula solar chulha/ biogas /fire food etc.)
(v) Disposal System
 Excreta :………………………………………………………………………………………………...............................................
(No latrine/open defecation/
Community latrine (sulabh or municipal/ house hold latrine /w.c./etc.)
 Refuse :………………………………………………………………………………………………...............................................
(Dustbin/open field /burning/
tipping /compositing/ community refusal disposal system)
 Sullage water :……………………………………………………………………………………………………………………...
(Soakpit/open drainage /closed drainage/Kitchen garden etc.)
(iv) Pet animals, specify with numbers : ……………………………………………………………………………………………….
(Dog/cat /goat/ cow/ pigs etc.)
 Immunization status of pet animals : ………………………………………………………………………………………………
(4) Health Risks and Hazards
(Present in the family)
(i) Physical Hazards :…………………………………………………………………………………………………………………….
(falls /slips /sharp tools/ open sockets fire/ swimming pool etc).
(ii) Cemical Hazards:……………………………………………………………………………………………………………………...
(medicine store/ insecticides/ explosive material/ petrol / chemicals etc.)
(iii) Habits:………………………………………………………………………………………………………………………………...
(defected daily activities of
Living (ADL) / drug abuse/ alcoholism/ smoking etc.)
(5) Health and Illness History
(i) Maternal and child health
 Mother
-Pregnancy at present (Yes/No.): ………………………………………………………………………………………………….
-if yes, No. of pregnancy: …………………………………………………………………………………………………………
-Duration of pregnancy: ………………………………………………………………………………………………………wks.
- TT Vaccination: …………………………………………………………………………………………...................................
-Anemia (observed /not present) :…………………………………………………………………………..................................
- Any other information:………………………………………………………………………………….....................................
About maternal health
-Children
- Number of children :………………………….(M……………………………….+F…………………………=………………)
- Number of children (under 5yr):………………………………………………………………………………………………...
Immunization Status of Children
OPV DPT
I II III B I II III B
O O
S. Vita A Any other
Name of Children Age Sex BCG O O MMR
No S S Solution Speci
T T
E E
R R
1.
2.
3.
4.
(ii) Family planning
 Eligible couple :……………………………………………………………………………………………………………………………..
(Observed /not observed)
 Users of contraceptives :……………………………………………………………………………………………………………………..
(if yes, give number of users )
 Preference of contraceptive :………………………………………………………………………………………………………………..
(Nimrod/pills/Cut etc.)
 Willingness for permanent sterilization:……………………………………………………………………………………………………
(Yes/No/halfhearted)
(iii) Record of vital statistics:…………………………………………………………………………………………………………………...
(brief description of family births and fdeaths )
(iv) Illness in family
 In illness, where family go for :……………………………………………………………………………………………………………
Treatment? Specify therapy

(Allopathy /Aruush : Ayurvedic, Yoga 7 naturopathy, unani, sidha and homeopathy )

 If any member is taking continue treatment:……………………………………………………………………………………………...
If yes , mention the medicine in brief;…………………………………………………………………………………………………….
And surgical history also, if occurred
 Details of members :………………………………………………………………………………………………………………………
Suffered with communicable diseases.
(v) Present health status of the family member: …………………………………………………………………………………………….
(iv) Health Resources :………………………………………………………………………………………………………………..
 Health agencies :………………………………………………………………………………………………………………………...
(SC/PHC/CHF/ Hospital etc.)
 Sources of health care providers :……………………………………………………………………………………………………....
 Voluntary health agencies :……………………………………………………………………………………………………………..
Or NGO’s of health care sector
 Utilization of health care :……………………………………………………………………………………………………………...
Agencies by family (mention in brief)
(6) Identification of health problems
(Mention the existing health problems according to their priorities)
(i) ……………………………………………………………………………………………….................
(ii) ………………………………………………………………………………………………………….
(iii) ………………………………………………………………………………………………………….
(iv) …………………………………………………………………………………………………………..
(v) ………………………………………………………………………………………………………….

Prepared by :…………………………………………................( Name) ………….………………………………………………..Signature

Supervised by :………………………………………………….( Name)……………………………………………………………Signature

 KESHLATA COLLEGE OF NURSING

COMMUNITY HEALTH NURSING

FAMILY FOLDER