This document contains a family profile data collection form for conducting a community health nursing assessment of a family. The form collects identification information about the head of household and family members. It also gathers data on the family's housing conditions, transportation/communication access, languages spoken, nutritional patterns, health status, pregnancy/maternal health, family planning practices, and treatment seeking behavior. Nursing diagnoses, goals, interventions and outcomes are to be documented. Vital signs are to be recorded on a graphic sheet. Notes from nursing visits are also to be recorded.

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COMMUNITY HEALTH NURSING
(NO. _____)
NAME OF STUDENTS :- _________________________________
CLASS :-__________________________________
DATE FROM :-________________ TO ______________

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FAMILY PROFILE DATA
Primary Health Centre: ________________________________
Sub Centre : _______________________________
Name of the Village: _________________________________
1. IDENTIFICATION INFORMATION
Head of family – Name:__________________________________________
Occupation : ___________________________________________________
Address_________________________________________________________________
________________________________________________________________________
Type of family: Nuclear Joint
Religion: Hindu Muslim Christian Any other
2. HOUSING CONDITION
1.Type of House: Completed Independent Tileld Sheeted
Hut Owned Rented
2. Rooms : Number - Adequate Inadequate
3. Kitchen : Separate Attached to room.
4. Fuel Used : Gas Kerosene Fire Wood Electricity
5. Ventilation : Adequate Inadequate
6. Bath Room : Separate Common
7. Lighting : Electricity Oil Lamp
8. Drainage : Open Close
9. Water Supply : Tap/Hand Pump Well Chlorined. - Yes/No Open Tank Chlorinated
10 Toilet : Own Public Open field
11 Disposal of Waste:Composing Burning Buying
12 Cattle Shed : Separate Within the House

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3. FAMILY COMPOSITION
S
N
Name Relationship
With Head
of the Family
Age Sex Education Occupation Health
Status
Immun
ization
Status
1
2
3
4
5
6
4. TRASPORT AND COMMUNICATION FACILITIES B. Communication Media
A. Transport Yes No
Own Yes/No Telephone
Tractor Tempo Wheeler Television
Bus City Bus RSRTC Private Radio
Autos Taxies Train Newspaper/Magazines
Post & Telegraph
5. LANGUAGES KNOWN
Marwadi Mewadi Gujrati
English Hindi Any Other
6. A)NUTRITIONAL PATTERN
Vegetarian Non Vegetarian
Staple Food : Rice Wheat Ragi Mixed
Vegetables : Grown Purchased Quantity used per day: ……kg
Milk : Quantity used per day ………litres
Non Vegetarian Dish: Specify…………………. How often ……………

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B) NUTRITIONAL STATUS OF FAMILY MEMBERS
Name of the Member Nourished/Under Nourished Malnutrition
7. RECORD OF ILLNESS
Name of the Member Age Illness Duration Main Investigation Treatment
Characteristics done
7. PREGNANT WOMAN
Name Age Gravida No. of Children Whether Registered in Receiving Iron
& Para Living Hospital/Nursing Home and Folio Acid
9. ELIGIBLE COUPLES
Name Age Family Planning Method Not interested willing to use
Adopted in Family Planning Family Planning method
10. IN CASE OF SICKNESS, WHERE DO YOU GO FOR TREATMENT?
Name/Primary Health Centre Private Nursing Home
Sub Centre Indigenous Doctor/Dai

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NURSING CARE PLAN
Assessment Nursing Diagnosis Objective/ Goals Nursing Interventions Evaluation Outcome

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Assessment Nursing Diagnosis Objective/ Goals Nursing Interventions Evaluation Outcome

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Vital Sign GRAPHIC SHEET
* Mouth
* Rectal
Month……………………….
Name, Age, Sex, Status Religion Hospital No.
Occupation, Income Ward, unit, Bed No.
B.P.
7a.m. to 7p.m.
(Total in m.l.)
Intake
7p.m. to 7a.m.
(Total in m.l.)
7a.m. to 7p.m.
(Total in m.l.)
Urine
7p.m. to 7a.m.
(Total in m.l.)
Stools No. of Times
Aspiration/Drainage
(24 Hrs. Total in m.l.)
Sputum
Weight
Bath
Date:
No. of Days
Days Post-op
Time
Pulse
Temp
C F
210 41.1 106
200 40.6 105
190 40.8 104
180 39.4 103
170 38.9 102
160 38.3 101
150 37.8 100
140 37.2 99
130 36.7 98
120 36.1 97
110 35.6 96
100 35 95
90 Resp-060
80 50
70 40
60 30
50 20
40 10

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NURSE’S NOTES
Date Time Nursing Intervention Signature