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Family Folder

The document contains a family assessment form with 53 questions covering topics like family members, income, housing, sanitation, healthcare access, and more. It collects key demographic and health-related information about families through closed-ended questions to assess living conditions and needs.

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vivion jacob
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998 views6 pages

Family Folder

The document contains a family assessment form with 53 questions covering topics like family members, income, housing, sanitation, healthcare access, and more. It collects key demographic and health-related information about families through closed-ended questions to assess living conditions and needs.

Uploaded by

vivion jacob
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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FAMILY FOLDER

Patient’s Name: _________________________________________


Father’s Name: ___________________________________________
Address: _________________________________________________
________________________________________________
________________________________________________

Date of visiting family:


________________________________________________________

Supervised by:

Submitted to:
________________________________________________________

Submitted by:
________________________________________________________
Family assessment form
Family folder no __________________
1. Name of the head of the family _______________________________________
2. Age______________________
3. Sex_______________________
4. House no. _________________
5. Name of the family members and their relationship with the head of the family

S.no Name Age Sex Relation with Education Occupation income


HOF

6. Type of family: joint/ nuclear


7. Religion __________________
8. Caste _____________________
9. Educational status _______________________
10. Language known: -
a. Mother tongue……………………………read/write/speak
b. Hindi…………………………………………. read/write/speak
c. English………………………………………. read/write/speak
d. Other…………………………………………. read/write/speak
11. Total monthly income of family ______________________________
12. Monthly expenditure _______________________________________
13. Occupation: -
a. Husband_________________________________
b. Wife ____________________________________
14. No and variety of animals. _______________________________________________
15. Other property bicycle/tv/radio/stereo
16. Sewing machine yes/no
17. Area of living rural/urban
18. Land owned yes/no
a. if yes: - cultivated/not cultivated
19. Type of house characteristics
a Kuccha/pucca/semi pucca_______________________________
b. Own/rented__________________________________________
c. No of rooms__________________________________________
d. Hygienic______________________________________________
20. Source of light………………………………. Electricity/candle/kerosene lamp
21. Ventilation adequate……………………. inadequate/absent
22. Water resources…………………………… tap/hand pump/well canal
23. Drainage………………………………………. open/closed/ no
24. Kitchen condition……………….………… hygienic/Unhygienic
25. Kitchen………….………………….…………. separate in veranda/in living room
26. Lavatory…………………….………………… own/public/open air
27. Fuel used………….…………………………. kerosene/lakadi/coal/gas
28. Methods of refuse disposal…………. burning/dumping/composing
29. Methods of excreta disposal………... open field/toilet
30. Shades of domestic’s animals………. absent/present
31. General environmental condition.…. safe/unsafe
32. Trees……………………………………………… yes/no
33. Duration of residence at the
Present address________________________________________________________
________________________________________________________
34.Transport
a. Own tempo/tractor
b. Govt bus/pvt bus
c. Train/tram
35.Communication media
a) Telephone.
b) Tv
c) Radio
d) Newspaper magazines
e) Post and telegraph
36. Economic condition
a) Income daily/monthly/yearly and amount________________________________
b) Total expenditure for food, fuel. housing, clothing__________________________
c) Debts due to sickness/marriage/others___________________________________

37. Cultural background


a. Food habits……………………………………………………… beg/non veg/both

FOOD AVAILABLE FOOD USED FOOD PREPARATION AND


STORAGE
Rice
Ragi
Jawar
Wheat
Vegetable
Fish
Meat
Egg
Milk
Milk powder
Pulses
Others

b. Attitudes……………………………………... spiritual/fatalistic/demonistic
c. Intra familial relationship………………. good/fair/tense/conflict
d. Cause of present illness as given by the family _____________________________
e. Effect of illness on any members of family _________________________________
f. Social and voluntary agencies working in the area ___________________________
38. Any deaths in the family. yes/no
a. Name _____________________________________________
b. Age _______________________________________________
c. Sex ________________________________________________
39. Is there any case of fever………. yes/no
a. With rigor……………. yes/no
b. With cough….………. yes/no
c. With rash……………… yes/no

40. Does anyone has skin disease……………………………… yes/no


41. Does anyone has a cough for more than 2 weeks… yes/no
42. Does anyone has any other illness?........................ yes/no
a) Give details
(name/disease/treatment) _______________________________________________
_____________________________________________________________________
43. Is any woman pregnant
a. Specify gravida ______________________________________________________
b. Has she been registered _______________________________________________
e. Is she getting IFA tablets _______________________________________________
d. Has she taken tetanus toxoid ___________________________________________
44. Has there been any vital statistics (within a year). ………. Yes/no
a. Birth
S. no. Date of birth Sex Parent’s name and name
b. Deaths
S. no. Name Cause of death Date of death

c. Marriages
S. no. Name Age/Sex Date of marriage

45. Are there any children below 5 years who have not received immunization? ….. yes/no
46. Is there any eligible couple………... yes/no
1. Are they using any contraceptive method?
o Oral pills
o Nirodh
o Any other
2. If not interested in using Family planning method (state reason)
47. Is there any child below 6 months in the family?
48. Is there any child who is physically handicapped/mentally?
49. Is there a well/hand pump?
1. Is it maintained in good order? ___________________________________________
2. When as the well last chlorinated? (date) ___________________________________
50. Is there any breeding place for insects and rodents? ……. Yes/no
51. Are there any street dogs in the vicinity? ………. yes/no
52. If anyone falls sick, which is the place for seeking treatment?
1. Hospital/PHC/SC/Pvt Nursing Home/Local Vaidya/Pvt Practitioner/Family doctor
53. Are official health agencies services adequate ……… yes/no

Date of survey
_________________________________
Signature of student
_________________________________

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