2. Name of the head of the family___________________________
House no.________ Caste___________
Area______________ Religion__________
Demograhic details :
Sr.
no.
Name Relation Age Sex Education Occupatio
n
Income Health
status
remark
3. Health Status –Immunization
For 0 to 05 years and A. N. Mothers
Sr.
no.
Name of
beneficiary
age status Oral
polio
DPT Measles D. PT.
Booster
D.T. T.T. Others
4. FAMILY PLANNING STATUS
S
R
.
N
O
.
Name of couple Status of
marriage for
yrs
No. of
children
Practicing f. p. Non
practicing f.
p. method
Reason Remark
T/V CC
5. NUTRITIONAL PATTERN
Staple food Type Pattern of diet Coking practice Food hygiene Eating
habit
Veg. Non.v
eg
b.f. b.f. lun
ch
din
ner
ext
ra
boil
ed
Pre
ssur
e
coo
ker
frie
d
washi
ng
Veg./
fruits
7. Sickness details
Name Diagnosis/c
omplaint
Duration Treatment Present
condition
Remark
hom
e
p.dis
pens
ary
Govt
.hos
p.
improve Not
improve
8. List Of Beneficiaries:
Sr.no. Name Age Sex Diagnosis Services
applied
9. Health Awareness Knowledge About
The Health Aspect
Sr,
no.
Health status Available
facilities
Utilization of
health
facilities
Reason for
utilization
Health
practices
superstition
10. ENVIRONMENTAL INFORMATION
SR
.N
O
HOUSING Water supply Drainage system Sewege disposal
locati
on
kacch
a
pucca floor Well
p/c
Bore
p/e
Tap
p/e
othe
r
open closed commo
n
Privat
e
latrin
e
comm
on
Com
mon
11. COMMUNITY IMPORTANT DAYS
SR
,N
O
BAZAR DAY WEEKLY PILGRMAGE
DAY
FAIR DAYS FESTIVAL
DAYS
SPORTS DAY NATIONAL
DAYS
13. NEEDS AND PROBLEM OF FAMILY
NEEDS :
PROBLEM :
14. PLAN OF CARE
PROMOTIONAL –PREVENTIVE/PROMOTIVE
CURATIVE –
REHABILITATIVE –
SR
.N
O
ASSESMENT NSG.DIAGNOS
IS
OBJECTIVE
GOAL
PLANNING INTERVENTIO
N
EVALUATIOJN
15. EVALUATION SUMMARY
SR
.N
O.
SERVICE PROVIDED DURATION OF
HEALTH CARE
PROGRESS
ACHIVED
SIGN OF S/N SIGN OF
SUPERVISOR
1 RESPONSE OF FAMILY
2 IMMUNIZATION
3 FAMILY PLANNING
4 MATERNAL CARE
ANC
INC
PNC
5 NUTRITION OTHER HEALTH
EDUCATION
6 GENERAL HEALTH CARE
7 DISEASE CONDITION
