COMMUNITY SURVEY FORMAT

                                                                                                                                                                              Date:

1.       IDENTIFICATION DATA:

Area: - Rural /Urban                                                            Name of the area:                                                                       

 Street:                                                                                   Door No:        

Name of Head of the family:                    

2.       FAMILY IDENTIFICATION:

a)       Total numbers of members in the families:

b)        Type of family:     Nuclear  /Joint/extended/single parent/other

c)       Religion: Hindu/Muslim/Christian/others

d)       Specify the sub-cast:

e)       Mother tongue:

f)        Family status: poor/middle/upper middle/upper class

g)       Total family income per month/per year

3.       STATEMENT OF EXPENDITURE IN THE FAMILY:

ITEMS	AMOUNT OF SPENT (approx.)	EXPENDITURE IN %
Food
Clothing
Housing rent
Health concerns
Children education
Recreation
Smoking/alcohol
Savings
Debt
Others
Total

    4. FAMILY CHARACTERISTICS :       

Sr. No	Name of family members	Relation with head of family	Sex	Birth year/ age	Education-al status	Occupation/ Income	Marital status	Health status	Remarks
1
2
3
4
5
6
7
8
9
10

5.       REPRODUCTIVE HISTORY:-

No. of eligible couple:

Family planning adopted: yes/no.   If yes specify:_____________________

Presence of pregnant women: yes/no      If yes specify:--

a)       Gravid:

b)       Para:

c)       Has been registered:

d)       Is she getting iron and folic acid drugs:

e)       Has been vaccinated with TT:

6.       HEALTH HISTORY:

a) Are there any children below 5 years, who have not received immunization?

S.NO

NAME

AGE

SEX

VACCINES

BCG

OPV

DPT

HEPATITIS-B

MEASLES

VITAMIN-A

1ST

2ND

3RD

1ST

2ND

3RD

1ST

2ND

3RD

1ST

2ND

3RD

b) Is there any fever cases? If yes,

S.NO	NAME	AGE	SYMPTOMS	TREATMENT	REMARKS

c) Does anyone have cough for more than 1 week?

S.NO	NAME	AGE	SYMPTOMS	TREATMENT	REMARKS

d) Does anyone have any skin diseases (e.g. patches. itching, rashes)

S.NO	NAME	AGE	SYMPTOMS	TREATMENT	REMARKS

e) Does anyone have any other illness like congenital /hereditary or genetic/communicable/non communicable diseases: yes/no if yes specify:__________

S.NO	NAME	AGE	SYMPTOMS	TREATMENT	REMARKS

7.       VITAL STATISTICS IN THE FAMILY (WITH IN ONE YEAR):

a) Birth:

b) Death:

c) Marriage:

8.       DIET HISTORY:

A)      Diet pattern:

Hygienic practices in cooking followed: yes/no

Food category: Vegetarian /Non vegetarian/Ova vegetarian

Cooking practices:--fresh preparation/storing                        -

Availability of food items:- fresh/stored or preserved

Cooking by:  Coal/ Wood/ Cow dung/ Kerosene oil stove/LPG Gas

B)       Nutritional status:

Name	Weight (kg)	Height (cm)	Body built				BMI (Normal 19-25)
			Thin	Moderate	Well	Obese	Below normal	Normal	Above normal

Nutritional deficiency: yes/no.  if yes specify: Anaemic/Goitre/Night Blindness/ Scurvy/Rickets/PEM/Others

S.NO	NAME	AGE	SYMPTOMS	TREATMENT	REMARKS

9.       HOUSING CONDITION:

Type of house: kuttcha/pucca/semipucca

Number of living room:

Living room space: Adequate/Inadequate

Kitchen condition: separate/corner of the house/verandas

Occupancy: Tenant/Owner/Monthly rent

Ventilation: adequate/inadequate/no ventilation

Sources of lighting: electricity/kerosene/others (specify)_____________

Water supply: tap water/ dug well/ bore well/lake/pond/river

Disposal of waste: open dumping/incineration/manual pits/others

Sullage water disposal: open drainage/closed drainage/soakage pit/kitchen garden

Refusal disposal: indiscriminate throwing/composting/burning/municipality collection

Excreta disposal: open air defecation/separate latrine/shared latrine/ public toilet

Presence of: Mosquitos/House flies/insects

Accident place environment: Sharp stone/Slippery floor/Open drainage/others

10.   TRANSPORT AND COMMUNICATION

a)       Transport: Own/Private/Government/Other

b)       Communication: telephone/TV/radio/newspaper/post/websites

11.    HEALTH CARE FACILITY:  PHC/SC/CHC/Private/Govt Aided

12.   EDUCATIONAL FACILITY:Balwadi/Schools/Colleges/Universities

13.    PRESENCE OF ORGANIZATION: GOVT ORGANIZATIONS/ NON GOVT. ORGANISATION (NGOS)                                                                                                                                                                  

                                                                                                                          

                                                                                                               Signature of the community health nurse:  __________________