Family folder

Head of the family: __________________________________

Fathers name _________________________________
Address __________________________________
__________________________________
__________________________________

Date of visiting family __________________________________

Supervised by Submitted to
_________________ __________________________________
_________________ __________________________________

Submitted by
_________________________________
_________________________________
Family assessment form
Family folder no_________________
1. Name of the head of the family__________________________
2. Age __________________
3. Sex ___________________
4. House no________________
5. Name of the family members and their relationships with the head of the family
S.no Name Age Sex Relationship Education Occupation Income
with HOF

6. Type of family: joint/ nuclear

7. Religion________________
8. Caste __________________
9. Educational status_________________
10. Language known
a. Mother tongue read/write/speak
b. Regional read/write/speak
c. Hindi read/write/speak
d. English read/write/speak
e. Others read/write/speak

11. Total monthly income of family ____________________________

12. Monthly expenditure ____________________________
13. Occupation
a. Husband ____________________________
b. Wife ____________________________
14. No and variety of animals ____________________________
15. Other property bicycle/tv/radio/stereo
16. Sewing machine yes/no
17. Land owned yes/no
18. Area of living rural/urban
a. If yes
i. Cultivated/not cultivated
 19. Type of house characteristics
a. Kuccha/pucca/semi pucca ____________________________
b. Own/rented ____________________________
c. No of rooms ____________________________
d. Hygienic ____________________________
20. Source of light electricity/candle/kerosene lamp
21. Ventilation adequate/inadequate/absent
22. Water resources tap/hand pump/well/canal
23. Drainage open/closed /no
24. Kitchen condition hygienic /unhygienic
25. Kitchen separate/in verandah/in living room
26. Lavatory own/public/open air
27. Fuel used kerosene/lakadi/coal/gas
28. Methods of refuse disposal burning/dumping/composing
29. Methods of excreta disposal open field/toilet
30. Shades of domestics animals absent./present
31. General environmental condition safe/unsafe
32. Trees yes/no
33. Duration of residence at the
Present address __________________________
34. Transport
a. Own tempo/tractor
b. Govt bus/pvt bus
c. Train/tram
35. Communication media
a. Telephone
b. Tv
c. Radio
d. Newspaper/magazines
e. Post and telegraph
36. Economic condition
a. Income- daily/monthly/yearly and amount ___________________
b. Total expenditure for food, fuel, housing, clothing etc______________
c. Debts due to sickness/marriage/others____________________________
37. Cultural background
a. Food habits veg/non veg/both

Food available Food used Food preparation and

storage
Rice
Ragi
Jawar
Wheat
Vegetable
Fish
Meat
Egg
Milk
Milk product
Pulses
Others

b. Attitudes spiritual/fatalistic/demonistic
c. Intra familial relationship good/fair/tense/conflict
d. Cause of present illness as given by the family________________
e. Effect of illness on any members of family __________________
f. Social and voluntary agencies working in the area_____________
38. Any deaths in the family yes/no
a. Name ____________________________
b. Age ____________________________
c. Sex ____________________________
39. Is there any case of fever yes/no
a. With rigor yes/no
b. With cough yes/no
c. With rash yes/no

40. Does any one has skin disease yes/no

41. Does anyone has a cough for more than 2 weeks yes/no
42. Does any one has any other illness? Yes/no
a. Give details
(name/disease/treatment)_______________________________________
43. Is any woman pregnant yes/no
a. Specify gravid ____________________________
b. Has she been regd ____________________________
c. Is she getting IFA tablets ____________________________
d. Has she taken tetanus toxoid ____________________________
44. Has there been any vital statistics(within a year) yes/no
a. Birth
S no Date of birth Sex Parent and name

b. Deaths
S no Name Cause of death Date of death

c. Marriages
S no Name Age/Sex Date of marriage

45. Are there any children below 5 years who have not received immunization? Yes/no
46. Is there any eligible couple yes/no
1. Are they using any contraceptive method
o Oral pills
 o Nirodh
o Any other
2. If not interested in using Family planning method(state reason)
____________________________________________________________________
47. Is there any child below 6 months in the family?
48. Is there any child who is physically handicapped/mentally? Yes/no
49. Is there a well/hand pump?
1. Is it maintained in good order ___________________________
2. When as the well last chlorinated?(date) ____________________________
50. Is there any breeding place for insects and rodents? Yes/no
51. Are there any street dogs in the vicinity yes/no
52. If anyone falls sick, which is the place for seeking treatment?
1. Hospital/PHC/SC/Pvt Nsg Home/Local Vaidhya/Pvt Practitoner/ Family
doctor
53. Are official health agencies services adequate yes/no

Date of survey

____________________

Signature of student

_____________________