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SRINIVAS COLLEGE OF NURSING, MANGALORE

DEPARTMENT OF COMMUNITY HEALTH NURSING

FAMILY FOLDER
BASELINE SURVEY FORM FOR COMMUNITY ASSESSMENT
1.

Name of the area Rural/Urban

............................................

2.

Name of the Health Centre

............................................

3.

Name of the Head of the Family ............................................

4.

Type of Family: 4:1 Single

...........................4.2 Joint...........................

5.

Religion: 5.1

Hindu

...................... (Specify the subcaste)..........................

5.2

Muslim

......................

.........................

5.3

Christian

......................

.........................

5.4

Any other

......................

.........................

6.

HOUSING CONDITION:

6.1

Type of house:
1) Pucca

6.2

Inadequate

2)

Owner

3)

Monthly Rent

2)

Inadequate

3)

No Ventilation

2)

Gas Lamp

3)

Oil Lamp

2)

Well

3)

Open Tank

2)

Corner of the room

3)

2)

Inadequate

No Drainage

2)

Public Latrine 3)

Veranda

Drainage:
1) Adequate

6.9

3)

Kitchen:
1) Separate

6.8

Adequate

Water Supply:
1) Tap/Handpump

6.7

2)

Lighting:
1) Electricity

6.6

Kutcha

Ventilation:
1) Adequate

6.5

3)

Occupancy:
1) Tenant

6.4

Semi Pucca

Rooms:
1) Number

6.3

2)

3)

Vatory
1) Own Latrine

Open Air Defecation

7.

FAMILY COMPOSITION:

Sr.
No.

7.A

8.

with Head

TOTAL INCOME OF FAMILY

Age

7.B

Sex

Education

Occupation

Income

EDUCATIONAL STATUS

NUMBER

a) Below 500

a) Not Literate

...............

b) 500 1000

b) Primary Education

...............

c) 1000 1500

c) Middle School

...............

d) 1500 2000

d) High School

...............

e) 2000 - & above

e) PUC & above

...............

TRANSPORT & COMMUNICATION MEDIA

8.2

9.

Relationship

Name

8.1

COMMUNICATION

1)

Transport

1)

Telephone.................

2)

Owns Tempo / Tractor............

2)

Television.................

3)

Uses B.T.S. / KSRTC.............

3)

Radio..................

4)

Uses Private Buses.................

4)

Newspaper/Magazine...........

5)

Train................

5)

Post & Telegraph.................

LANGUAGE:
1)

Mother Tongue..................

1)

Kannada Read/Write

2)

Punjabi......................

2)

English Read Write

3)

Hindi....................

3)

Punjabi Read/Write

4)

Others...............

4)

Specify others.....................

DIETARY PATTERN:
Food Available

Rice
Ragi
Jawar
Wheat
Vegetable
Fish
Meat
Egg
Milk and Products
Pulses
Tubers

Foods Used

Food Preparation and Storage


Traditional
Ideal
Unhygienic

Others
10.

STATEMENT OF EXPENDITURE OF THE FAMILY:

Sr.

Item

No.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

Amount Spent (Approx)

% of Total Expenditure

Food
Clothing
Housing (Rent)
Medicine
Children Education
Recreation (Movies Etc.)
Smoking & or Liquor
Debt
Savings
Others (Specify)
Is there any case of fever (If yes, write name, age, treatment with remarks)

With Rigors?
With Cough?
With Rash?
Sr.
No.
1.
2.
3.
12.

Name

Name

Name

Remarks

Age

Disease

Treatment

Remarks

Age

Disease

Treatment

Remarks

Treatment

Remark

DOES ANYONE HAVE ANY OTHER ILLNESS?

Sr.

Name

No.

15.

Treatment

DOES ANYONE HAVE A COUGH MORE THAN TWO WEEKS?

Sr.
No.
1.
2.
3.
14.

Disease

DOES ANYONE HAVE ANY SKIN DISEASE (Eg. Itching, Patch, Rash)?

Sr.
No.
1.
2.
3.
13.

Age

Age

Disease

HAS ANY WOMEN PREGNANT? If yes, write the following remarks.

Specify gravida.
Has she been registered?
Is she getting Iron and Folic acid?

Has she had Tetanus Toxoid?


Sr.

Name

No.
1.
2.
3.
16.

15.1

15.2

15.3

15.4

HAVE THERE BEEN ANY (within year) Vital Statistics.

BIRTH?
Sr.
No.
1.
2.
3.
DEATHS?
Sr.
No.
1.
2.
3.
MARRIAGES?

17.

Date of Birth

Sex

Parents Name

Remarks

Date of Birth

Sex

Parents Name

Remarks

Name
Age
Date of Marriage
Remark
Bride
Bridegroom
ARE THER ANY CHILDREN BELOW FIVE YEARS WHO HAVE NOT RECIEVED
IMMUNISATION (Specify name, age, reason, for not immunises in remarks)

B.C.G. VACCINATION
D.P.T. VACCINATION
POLIOMYELITIS VAC
MEASLE VACCINATION
VIT. A. SOLUTION
Sr.
No.
1.
2.
3.
4.

Name

Age

Sex

17.1

17.2
2

17.3

17.4

17.5

Remarks..............................................................................................................................................................
..........
18.
IS THERE ANY ELIGIBLE COUPLE: (if so list them on priority)
Sr.
No.
1.
2.
3.
18.1

Name

Age

Sex

I Priority

II

Primary

Secondary

Early

Priority

Sterility

Sterility

Menopause

Using a contraceptive method? Is yes specify.................

18.2

Intending to undergo

18.2.1 Vasactomy......................................
18.2.2 Tubal Ligation...................................

18.3
19.

Not interested to adopt F.P. Method (State the reason)


IS THERE ANY CHILD 0 5 YEARS IN FAMILY WHO SHOW SIGNS OF: MALNUTRITION

Kwashiorkor?
Marasmus?
Vit. A. Deficiency?
Anemia?
Rickets?

Sr.

Name

No.

Age

19.1

19.2

19.3

19.4

19.5

Remarks..............................................................................................................................................................
..........
20.

Is the sullage water being disposed of hygienically? If yes Tick any one/all
1. Drain

2.

Soakpit

3.

If

Kitchen Garden
no

State

Reasons..................................................................................................................................................
21.

Is the rubbish being disposed hygientcally? If yes Tick any one.all


1. Composing

22.

2.

Burning

3.

Burying

Is the excreta being disposed hygienically? Yes/No, If no state reason.

State
Remarks.......................................................................................................................................................
23.

Are the cattle and poultry house hygienically?

State
Reasons.......................................................................................................................................................
24.

Is there is a well or handpump?

24.1

Is it maintained in good order. If no state reasons

24.2

Where was the well chlorinated?

Yes

No

Date? If no state reasons

25.

Whether house kept clean? If no state reasons

26.

When was the house last sprayed?

Yes

Yes

No

Yes

No

No

Date? If no state reasons

27.

Is there any breeding place of insects and rodents?

Yes

28.

Are there any stray dogs in the vicinity? If yes write approximate number of dogs.

29.

If anyone falls ill where do you get treatment?

Yes

No

Yes

No

No
Yes

No

Hospital/Primary Health Centre.


Subcentre Primary Health Unit.
Private Nursing Homes.
Indigenous Doctor/Local Vaidya.
30.

Is official health agencies services adequate?

If

No

state

reasons......................................................................................................................................................
Note:

In an addition to the above students are expected to obtain following information by


observations and other methods.

1.

Description of the community location, topography, climate, history etc. Type government, No. of
schools, No. of health care agencies, Balwadi of ICDS centre places of worship (eg. Temple) and
any other relevant information related to health.

2.

List the target couple with details on priority basis.

3.

Maintain record of Road to Health Card for knowing the degree of malnutrition for under 5s
wherever necessary and use Nutritional Assessment Form promptly.

4.

Use problem solving approach/construct good nursing care plan by using PRONE format taught
you in recent Community Nursing Process Lectures.

5.

Remarks can be written in separate sheets quoting code no.


(For eg. 13.2 No. sensations found on the patches needs referral and follow up services).
Date of Survey

Name & Signature of Student