family survey during community posting for MBBS final Pt-I Std. in community medicine subject

1. FAMILY SURVEYFAMILY SURVEY
OBJECTIVESOBJECTIVES
 To familiarize with the concept of communityTo familiarize with the concept of community
medicine/community health.medicine/community health.
 To know about the role of environmental hostTo know about the role of environmental host
factors in health and disease with specialfactors in health and disease with special
reference to family.reference to family.
 To provide comprehensive health care to theseTo provide comprehensive health care to these
families under the supervision of departmentalfamilies under the supervision of departmental
staff.staff.

2. Main HeadingsMain Headings
1.1. General information including Family composition.General information including Family composition.
2.2. Child health record (Immunization status of all under five)Child health record (Immunization status of all under five)
3.3. Physical environment with special emphasis on –Physical environment with special emphasis on –

Housing Condition:Housing Condition:

Water supplyWater supply

Sewage disposalSewage disposal

Refuse disposal etc.Refuse disposal etc.
4.4. Biological environmentBiological environment
5.5. Meteorological environmentMeteorological environment
6.6. Nutritional/Dietary assessmentNutritional/Dietary assessment
7.7. Health status of Family member (Individual health record) withHealth status of Family member (Individual health record) with
personal hygiene.personal hygiene.
8.8. Schedule for Eligible couple with their contraceptive historySchedule for Eligible couple with their contraceptive history
9.9. Schedule for antenatal caseSchedule for antenatal case

Obstetric history with high risk approachObstetric history with high risk approach

History of previous pregnancyHistory of previous pregnancy

Obstetric examination progress of pregnancy)Obstetric examination progress of pregnancy)
 Summary of family details and recommendationSummary of family details and recommendation

3. GENERAL INFORMATION SCHEDULEGENERAL INFORMATION SCHEDULE
a.a. Family no.:-………… b.Family no.:-………… b. House hold no.:-……….House hold no.:-……….
c.c. Name of the head of family:-………..Name of the head of family:-………..
d.d. Address:-………………………..Address:-………………………..
e.e. Religion:-……………. f. Caste:-………..Religion:-……………. f. Caste:-………..
g.g. Occupation of head:-……………Occupation of head:-……………
h.h. Type of family:-Single/Nuclear/JointType of family:-Single/Nuclear/Joint
i.i. Monthly income…………..Monthly income………….. Rs./monthRs./month
j.j. Per capita income…………Per capita income………… Rs /monthRs /month
k.k. Amount spent on food…….Amount spent on food……. Rs. /monthRs. /month
l.l. Amount spent on education…Amount spent on education… Rs./monthRs./month
m.m. Amount spent on housing…..Amount spent on housing….. Rs/monthRs/month
n.n. Spent on medical care………Spent on medical care……… Rs/monthRs/month
o.o. On clothingOn clothing ……………… Rs/monthRs/month
p.p. On otherOn other ……………… Rs/monthRs/month
q.q. Monthly savings……………..Monthly savings…………….. Rs/monthRs/month

4. GENERAL INFORMATION SCHEDULEGENERAL INFORMATION SCHEDULE
FAMILY COMPOSITION / INDIVIDUAL SCHEDULEFAMILY COMPOSITION / INDIVIDUAL SCHEDULE
S.No.S.No. 11 22 33 44 55 66 77 88
NameName
AgeAge
Sex M/FSex M/F
RelationRelation
With headWith head
EducationEducation
OccupationOccupation
IncomeIncome
Type of workType of work
(Sedentary/(Sedentary/
Moderate/Moderate/
Heavy)Heavy)

5. 2.2. CHILD HEALTH RECORDCHILD HEALTH RECORD
Name………. Dt. Of birth…. Sex….age….. father`s name………Name………. Dt. Of birth…. Sex….age….. father`s name………
Birth weight…….. Birth order……..Date of weaning……Birth weight…….. Birth order……..Date of weaning……
Ht.in Cms…….Congenital defect if any……….Ht.in Cms…….Congenital defect if any……….
Immunization statusImmunization status
 VaccineVaccine ageage datedate
 BCGBCG
 DPTDPT I/II/IIII/II/III
 OPVOPV O/I/II/IIIO/I/II/III
 MeaslesMeasles
 MMRMMR
 Vit.A supplementationVit.A supplementation
 Booster OPV/DPTBooster OPV/DPT I/III/II
Completely Immunized / Partially Immunized / UnimmunizedCompletely Immunized / Partially Immunized / Unimmunized

6. HemoglobinHemoglobin -……………gm%-……………gm%
StoolStool -…………..-…………..
DietDiet
Adequate/InadequateAdequate/Inadequate
………………gm deficient in proteingm deficient in protein
………………K cal deficient / excessK cal deficient / excess
Follow up visitFollow up visit
DtDt.. AgeAge HtHt.. WtWt.. S/SS/S advise/treatmentadvise/treatment
CHILD HEALTH RECORDCHILD HEALTH RECORD
Laboratory Examination/Diet/Follow up visitLaboratory Examination/Diet/Follow up visit

7. 3.3. PHYSICAL ENVIRONMENTPHYSICAL ENVIRONMENT
a.a. Locality – very congested / moderate / openLocality – very congested / moderate / open
b.b. Type of house – Pucca /semi Pucca/ katchaType of house – Pucca /semi Pucca/ katcha
- Roof- Roof - thatched/tiled/concrete………...- thatched/tiled/concrete………...
- Walls- Walls - mud/brick/stone……….- mud/brick/stone……….
- Floor- Floor - mud/ brick/concrete/…….- mud/ brick/concrete/…….
c.c. white washwhite wash - every year/occasional/…..- every year/occasional/…..
d.d. DampnessDampness - absent / present- absent / present
e.e. Number of rooms:…………..Number of rooms:…………..
-- Area of each room:1….2….3…Area of each room:1….2….3…
-- Total area of rooms…Sq. meter.Total area of rooms…Sq. meter.
-- Total area:……….per personTotal area:……….per person
f.f. No. of windows:…..Screened:- yes / noNo. of windows:…..Screened:- yes / no
g.g. Cross ventilations: present/ not presentCross ventilations: present/ not present

Cross ventilations present in…roomsCross ventilations present in…rooms
h.h. Ventilations:- adequate / not adequateVentilations:- adequate / not adequate

Adequate only in……….roomsAdequate only in……….rooms

Door window to floor space ration………Door window to floor space ration………

8. 3.3. PHYSICAL ENVIRONMENTPHYSICAL ENVIRONMENT
i.i. Lightings:- adequate/ not adequateLightings:- adequate/ not adequate
j.j. Kitchen: separate / not separateKitchen: separate / not separate
k.k. Chula (fuel): smoky / smokelessChula (fuel): smoky / smokeless
l.l. Drainage: - adequate / not adequateDrainage: - adequate / not adequate
m.m. Bath room (private): - present / not presentBath room (private): - present / not present
n.n. Water supply (drinking):-Water supply (drinking):-

Source-Source- open well Kutcha or pucca / sanitary well / hand pump / tank /open well Kutcha or pucca / sanitary well / hand pump / tank /
piped.piped.

Source present in houseSource present in house – yes / no.– yes / no.

If no………If no……… meter away from housemeter away from house

Quantity –Quantity – adequate / not adequateadequate / not adequate

Approximately……Approximately…… liters/personliters/person

Storage –Storage – sanitary / not sanitarysanitary / not sanitary
o. Refuge disposalo. Refuge disposal -indiscriminate / burning / dumping /-indiscriminate / burning / dumping /
compostingcomposting
p. Disposal of night soilp. Disposal of night soil - septic tank / service privy / open- septic tank / service privy / open
field/otherfield/other

9. 4.4. BIOLOGICAL ENVIRONMENTBIOLOGICAL ENVIRONMENT
a.a. Animal – Present/Not;Animal – Present/Not;

Type of animal…….Type of animal…….

Animal keepingAnimal keeping -- present/absentpresent/absent

Separate/attachedSeparate/attached
b.b. Breeding place of house fly / mosquito inBreeding place of house fly / mosquito in
the compound – present / absentthe compound – present / absent
c.c. Rodent – present / absentRodent – present / absent

10. 5.5. METEOROLOGICAL ENVIRONMENTMETEOROLOGICAL ENVIRONMENT
 High temperatureHigh temperature
II Local effects:Local effects:
-Darkening of skin, prickly heat, sun burn, dermatitis-Darkening of skin, prickly heat, sun burn, dermatitis
IIII General effects:General effects:
- Heat stroke- Heat stroke
- Heat exhaustion- Heat exhaustion
- Heat cramps- Heat cramps
 Low temp. or cold climateLow temp. or cold climate
- Frost bite, Trench foot- Frost bite, Trench foot
- Cold, bronchitis, pneumonia etc.- Cold, bronchitis, pneumonia etc.
 HumidityHumidity
- It makes the warm climate warmer and- It makes the warm climate warmer and
- cold climate colder- cold climate colder
 Movement of airMovement of air

11. 6.6. NUTRITIONAL / DIETARY SURVEYNUTRITIONAL / DIETARY SURVEY
Intake of Food in gramsIntake of Food in grams
Food ItemsFood Items Weekly/Weekly/ Total dailyTotal daily Protein(gm)Protein(gm) Calorie cal)Calorie cal)
averageaverage averageaverage
Cereals – Rice / Wheat / othersCereals – Rice / Wheat / others
PulsePulse 1./ 2./ 3.1./ 2./ 3.
Roots & TuberRoots & Tuber
Leafy vegetablesLeafy vegetables
MilkMilk
Meat, fishMeat, fish
EggEgg
Sugar & jeggarySugar & jeggary
Oil & GheeOil & Ghee
FruitsFruits
MiscellaneousMiscellaneous
a.a. Food habits – Vegetarian / non-vegetarian(regular/occasionalFood habits – Vegetarian / non-vegetarian(regular/occasional
b.b. Total no. of consumption unit………Total no. of consumption unit………
c.c. Daily Protein Consumption…Daily Protein Consumption…
d.d. Daily Calories Consumption…Daily Calories Consumption…
e.e. Per Consumption unit protein used…Per Consumption unit protein used…
f.f. Per consumption unit Calories used…Per consumption unit Calories used…
g.g. Protein excess / deficient…gm/ Consumption/dayProtein excess / deficient…gm/ Consumption/day
h.h. Calories excess / deficient….K. cal /Consumption unit / dayCalories excess / deficient….K. cal /Consumption unit / day

12. 6. Health Status of Family Member6. Health Status of Family Member
(Individual Health Record)(Individual Health Record)
Name…..Age….Sex…..Occupation……Name…..Age….Sex…..Occupation……
H/O of Past illness / Injuries if any……H/O of Past illness / Injuries if any……
Present complaint if any………Present complaint if any………
H/O of Present illness……….H/O of Present illness……….
Personal history – addiction/diet/hobbiesPersonal history – addiction/diet/hobbies
Weight…..Wt….Temp…. Skin & Hair…….Patches…..Weight…..Wt….Temp…. Skin & Hair…….Patches…..
ENT & mouth : (tonsils), oral hygieneENT & mouth : (tonsils), oral hygiene
Eye conditionsEye conditions
CVS: Heart, blood vessels, B.P.CVS: Heart, blood vessels, B.P.
Respiratory (chest):Respiratory (chest):
Alimentary (Abdomen):Alimentary (Abdomen):
Lymph glandsLymph glands
CNS examinationCNS examination
Positive findings of nutritional deficiency disease if any.Positive findings of nutritional deficiency disease if any.
Laboratory examinationLaboratory examination

13. 6. Health Status of Family Member6. Health Status of Family Member General ExaminationGeneral Examination
Chest circumferenceChest circumference………Mid upper arm circumference………Mid upper arm circumference
General appearanceGeneral appearance – Normal/Thin/Sickly/fatty– Normal/Thin/Sickly/fatty
Hair sign-Hair sign- Normal/dull & dry/ Dyspigmentation/Sparse/ easily plukable/flagNormal/dull & dry/ Dyspigmentation/Sparse/ easily plukable/flag
Eyes-Eyes- - Conjunctiva – normal/dry on exposure/ dry & wrinkled/ bittot`s spot/ angular- Conjunctiva – normal/dry on exposure/ dry & wrinkled/ bittot`s spot/ angular
conjunctivitis / pale conjunctivaconjunctivitis / pale conjunctiva
- Cornea- Cornea - Normal/dry / hazy or opaque- Normal/dry / hazy or opaque
LipsLips- Normal/ angular stomatitis / cheilosis- Normal/ angular stomatitis / cheilosis
TongueTongue - Normal/ pale and flabby/ red & raw / fissured/ geographic- Normal/ pale and flabby/ red & raw / fissured/ geographic
GumGum - Normal/ bleeding- Normal/ bleeding
GlandsGlands - Normal/enlargement ( name)- Normal/enlargement ( name)
SkinSkin - Normal / dry and scaly / Follicular hyperkeratosis- Normal / dry and scaly / Follicular hyperkeratosis
NailsNails - Normal / koilonychias / pale- Normal / koilonychias / pale
OedemaOedema - Absent / present on dependent part- Absent / present on dependent part
RachiticRachitic - Knock-knee or bow leg/ Epiphyseal enlargement/Beading of changes- Knock-knee or bow leg/ Epiphyseal enlargement/Beading of changes rib/rib/
Pigeon chest/ nonePigeon chest/ none
AbdominalAbdominal .- Hepatomegaly / Splenomegaly.- Hepatomegaly / Splenomegaly / other…/ other…
CVSCVS - Cardiac enlargement / tachycardia / others…- Cardiac enlargement / tachycardia / others…
OthersOthers - Psychomotor changes / mental confusion / sensory loss / motor weakness /- Psychomotor changes / mental confusion / sensory loss / motor weakness /
loss of position sense / loss of vibration sense / loss of ankle & Knee jerks /loss of position sense / loss of vibration sense / loss of ankle & Knee jerks /
calf tendernesscalf tenderness
Any other abnormalityAny other abnormality………….………….

14. 6. Health Status of Family Member6. Health Status of Family Member Personal HygienePersonal Hygiene
S. No.S. No. 11 22 33 44 55
Name….Name….
Skin Clean Y/NSkin Clean Y/N
Nail cutNail cut Y/NY/N
Hair LouseHair Louse Y/NY/N
Hair cleanHair clean Y/NY/N
BathBath daily / irregulardaily / irregular
Use of soap Y/NUse of soap Y/N
TowelTowel Separate/mixedSeparate/mixed
Oral HygieneOral Hygiene Good/poorGood/poor
Foot wearFoot wear Y/NY/N
ExerciseExercise Y/NY/N

15. 7. Schedule for Eligible Couple7. Schedule for Eligible Couple
Name of Wife……………………………….Age…Name of Wife……………………………….Age…
Name of Husband………………………….AgeName of Husband………………………….Age
Obstetric HistoryObstetric History
Date of Marriage…………Para……….Gravida……….Date of Marriage…………Para……….Gravida……….
Age at first delivery……Age at last delivery……..Age at first delivery……Age at last delivery……..
Total no. of abortion………….Total no. of abortion………….
Total no. of living children – male / femaleTotal no. of living children – male / female
Additional children wanted….Additional children wanted….
Gynecological HistoryGynecological History
LMP….Menarche….yrs Cycle…..daysLMP….Menarche….yrs Cycle…..days
Dysmenorrhoea – Y/N (if yes take detail H.)Dysmenorrhoea – Y/N (if yes take detail H.)
Vaginal discharge – Y/N (if Y take detail H.)Vaginal discharge – Y/N (if Y take detail H.)
Previous Pelvic infection – Y/NPrevious Pelvic infection – Y/N

16. 7. Schedule for Eligible Couple7. Schedule for Eligible Couple
Contraceptive historyContraceptive history
 Practicing Currently – none/condom/IUD/OP/Practicing Currently – none/condom/IUD/OP/
Sterilization (M/F)/other...Sterilization (M/F)/other...
 Ever practiced – none/ condom/IUD/OP/ other...Ever practiced – none/ condom/IUD/OP/ other...

If ever practiced reason for discontinuity….If ever practiced reason for discontinuity….
 Reason for family planning:Reason for family planning:

Limitation/spacing/undecided/other….Limitation/spacing/undecided/other….
Type of coupleType of couple: eligible/target: eligible/target

17. 8.8. SCHEDULE FOR ANTENATAL CASESCHEDULE FOR ANTENATAL CASE
Name…………….Age………Name of husband……..Age……Name…………….Age………Name of husband……..Age……
Obstetric historyObstetric history
Amenorrhoea……wkAmenorrhoea……wk Date of marriage…………Para…..Gravida……Date of marriage…………Para…..Gravida……
Age at first pregnancy / delivery………….Age at first pregnancy / delivery………….
Age at last pregnancy / delivery…………..Age at last pregnancy / delivery…………..
Total n. of abortion………..Total n. of abortion………..
Total no. of living children Male……….female………Total no. of living children Male……….female………
Additional children wanted………. Give reason…………….Additional children wanted………. Give reason…………….
LMP………….EDD………..LMP………….EDD………..
Immunization – TTImmunization – TT I dose date…II dose date…I dose date…II dose date…
Additional nourishment Y/NAdditional nourishment Y/N
ComplaintComplaint Y/NY/N

18. 8.8. SCHEDULE FOR ANTENATAL CASESCHEDULE FOR ANTENATAL CASE
Obstetric examination progress of pregnancy)Obstetric examination progress of pregnancy)
Date………Date………
Height of fundus……. Foetal heart sound…..Height of fundus……. Foetal heart sound…..
Position presentation…..Position presentation…..
Foetal head:- floating / engagedFoetal head:- floating / engaged
Weight…. BP….. Hb%…..Weight…. BP….. Hb%…..
Urine:-Urine:- Albumin…… Sugar……Albumin…… Sugar……
Oedema:-Oedema:- absent / presentabsent / present
Blood group:-…..Blood group:-…..
VDRLVDRL +ve / -ve+ve / -ve

19. History of Previous PregnancyHistory of Previous Pregnancy
Pregnancy no.Pregnancy no. 1/2/3/…1/2/3/…
Date of delivery:……….Date of delivery:……….
Antenatal careAntenatal care Y/NY/N
Antenatal care byAntenatal care by Doctor/LHV/ANM/TBA/untrained daiDoctor/LHV/ANM/TBA/untrained dai
Place of deliveryPlace of delivery Home/hospitalHome/hospital
Attended byAttended by

Doctor/LHV/ANM/TBA/untrained daiDoctor/LHV/ANM/TBA/untrained dai
Result of birth – full term/pre-mature/still birthResult of birth – full term/pre-mature/still birth
AbortionAbortion
Birth weight….Birth weight….
Any complication ……..Any complication ……..
8.8. SCHEDULE FOR ANTENATAL CASESCHEDULE FOR ANTENATAL CASE

20. 9. SUMMARY AND RECOMMENDATION9. SUMMARY AND RECOMMENDATION
a.a. Summary of the health need of the familySummary of the health need of the family

Physical:Physical:

Environmental:Environmental:

Meteorological:Meteorological:

Mental:Mental:

Socio Economic:Socio Economic:

Behaviour:Behaviour:

Disorder:Disorder:
b.b. Summary of the health status of familySummary of the health status of family
c.c. Summary of nutritional status of familySummary of nutritional status of family
d.d. Recommendation for improving the Socio-Recommendation for improving the Socio-
economic, environmental, and health status ofeconomic, environmental, and health status of
familyfamily