Socio Demographic Data

First Contact on________________________________________________________________

C.R.No._______________________________ Psy.No._________________________________
Name_____________________________________ Age & Sex__________________________
S/o, D/o, W/o Sh._______________________________________________________________
Local Address and Telephone _____________________________________________________
_____________________________________________________________________________
E-Mail ID_____________________________________________________________________
Permanent Address_____________________________________________________________
_____________________________________________________________________________
Marital Status: 1. Single 2. Married 3. Remarried 4. Widow 5. Divorced 6. Separated 7. Others
8. Not Known
Occupation: 1. Professional 2.Semi Professional 3. Clerical/Shop-owner/farmer 4. Skilled/
Semi skilled/Un-skilled worker 5. Housewife /Household 6. Retired
7. Unemployed/Student 8. Not Known
Education:
1. Illiterate 2. Primary 3. Middle 4. Matric 5. Inter /Diploma 6. Graduate 7. Post
Graduate 8. Professional/Honors 9. Not Known
Income:
1. 0 -3500 2. 3501-7000 3. 7001- Above
(In Rs/Month)
Religion:
1. Hinduism 2. Islam 3. Sikhism 4. Christianity 5. Others 6. Not Known
Family Type: 1. Nuclear 2. Extended 3. Joint 4. others 5. Not known
Locality:
1. Urban 2. Rural 3. Others 4. Not Known
Residence: Permanent resident of: 1. Punjab 2. Haryana 3. Chandigarh 4. Himachal Pradesh
5. U.P 6. Others (Specify)_______________________
Referred From: 1. Direct 2. Medical/Surgical/ Other OPDs 3.Relative 4. NGO/Other welfare
Agencies 5. Others (Specify)_____________________ 6. Not Known
Language Known: 1. Hindi 2. Punjabi 3.Urdu 4. English 5. Others (Specify)_______________
Insight:_____________________ Non Compliance___________________________________

-SIGNATURE