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Family health survey format

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Family health survey format

  1. 1. Form ID: 1 Department of Community Medicine VMCH & RI, Madurai Family health survey General info 1. House no. / EB no. 2. Street or area name 3. Name of head of the family 4. Education of the head of the family 5. Occupation of the head of the family 6. Total family income Rs. 7. Total no. of family members 8. Type of the family 1. Nuclear 2. Extended 9. Religion of the family 1. Hindu 2. Islam 3. Christianity Family members No. Name Age (yr) Sex Relation with head Marital status Edu Occu Income Per month 1. 0 2. 3. 4. 5. 6. 7. Codes: Sex: 1-Male, 2-Female Relation with head 0-Head 1-Wife 2-Husband 3-Son 4-Daughter 5-Son in law 6-Daughter in law 7-Grand children 8-Other (uncle, aunt, nephew, niece etc.,) Marital status: 1-Never married 2-Currently married 3-Divorced 4-Widowed 5-Separated Education: 1-Not yet started school 2-Still studying 3-No formal schooling but can read and write 4-Completed primary school (1-5 std) 5-Completed middle school (6-8 std) 6-Completed secondary school (9-10 std) 7-Completed higher secondary school (11-12 std) 8-Completed diploma 9-Completed college degree Occupation: (only for persons aged 14 and more) 1-Still studying or student 2-Unemployed (not studying, not working) 3-Retired from work (for persons aged >60 years) 4-Unskilled 5-Semiskilled, 6-Skilled Income: Ask about the usual income per month Add income from rent and other sources to the total family income.
  2. 2. Form ID: 2 Environmental sanitation 10. Type of house 1. Kutcha 2. Pucca 3. Semi-pucca 11. No. of living rooms 12. Overcrowding 1. Present 2. Absent 13. Ventilation 1. Adequate 2. Inadequate 14. Lighting 1. Adequate 2. Inadequate 15. Kitchen location 1. Separate room 2. Within a room used for other purpose 3. Outside the house 16. Kitchen type 1. Smokeless 2. Smoky 17. Bathroom 1. Present within house 2. Present outside house 3. Absent 18. Sanitary latrine 1. Present and using 2. Present but not using 3. Absent 19. Drainage 1. Proper 2. Improper 20. Source of drinking water 1. Hand pump within house 2. Public hand pump 3. Municipal pipe in house 4. Public tap 5. Well within house 6. Public well 7. Pond 8. Mineral/RO water bought from shops in cans 9. Tube well within house 10. Others:____________________________ Over crowding criteria Rooms Persons 1 2 2 3 3 5 4 7 5 10
  3. 3. Form ID: 3 Maternal health (fill only for married women in 15-45 years age group who have been pregnant in the last five years) Name Age at marriage No. of pregnancies in last 5 years (including abortions) No. of children born in last 5 years Whether TT taken during last pregnancy Whether IFA taken during last pregnancy (approx.. 100 tablets) Place of delivery of last pregnancy Last pregnancy outcome Present status of last child born alive (fill only if alive in prev. column) 1 1. Yes 2. No 1. Yes 2. No 1. Hosp 2. Home 1. Alive 2. Stillbirth 3. Aborted 1. Alive 2. Dead 2 1. Yes 2. No 1. Yes 2. No 1. Hosp 2. Home 1. Alive 2. Stillbirth 3. Aborted 1. Alive 2. Dead 3 4 5 Currently pregnant women (fill only if there is a currently pregnant women in the house) Name Which trimester? Registered or not so far? No. of visits TT1 TT2 TT Booster IFA received so far or not Choice of delivery place 1 1. First 2. Second 3. Third 1. Yes 2. No 1. Yes 2. No 1. Yes 2. No 1. Yes 2. No 1. Yes 2. No 1. Home 2. Govt. 3. Pvt. 2 3
  4. 4. Form ID: 4 Child feeding practices (fill only for children below 2 years) No. Name Age (mo) Prelacteal feed Type of prelacteal feed given Breast feeding Type of weaning food Initiation time EBF time When stopped given at start (hours after (mo) completely (mo) birth) 1 1. Given 2. Not given 1. Sugar water 2. Honey 3. Animal milk 4. Holy water 5. ___________ 99. Not at all given 1. <30 min 2. 30 min-1hr 3. 1-4hr 4. >4hr 99. Not at all given 1. <6 months 2. >6 months 99. Not at all given 1. <6 months 2. 6 mo-1 yr 3. > 1 year 99. Not yet started 1. animal milk 2. rice 3. dal 4. vegetable 5. kichdi 6. cerelac, nestum, lactogen, milk powder 7. others ____________________ 2 3 Immunization (fill only for children aged 12 to 24 months at present) No. Name Whether immunization card present BCG, OPV 0 dose OPV, Pentavalent Measles Reasons: If any 1 2 3 vaccine is not given 1 1. Yes 2. No 1. Yes 2. No 1. Yes 2. No 1. Yes 2. No 1. Yes 2. No 1. Yes 2. No 2
  5. 5. Form ID: 5 Health care utilization No. When some one in your family falls sick, where do you go for treatment? (Write the most common option) 1. We don’t go anywhere, prefer home remedy 2. Local healer 3. Govt. hospital 4. Pvt. qualified doctor 1 Reasons for preferring this option (only for options 2,3,4) 1. Known to us 2. Comfortable 3. Cheap 4. Recommended by friends or relatives 5. Others _______________ Diabetes and Hypertension No. Name What disease? Whether currently taking treatment? What type of treatment? Regularity of treatment 1 1. HTN 2. Diabetes 3. Both 1.Yes 2. No 1. Allopathic 2. Alternative medicine 3. Both 1. Regular 2. Irregular 2 3

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