Family health survey

General info
1. House no. / EB no.
2. Street or area name
3. Name of head of the family
4. Education of the head of the family
5. Occupation of the head of the family
6. Total family income Rs.
7. Total no. of family members
8. Type of the family 1. Nuclear 2. Joint 3. Extended
9. Religion of the family 1. Hindu 2. Islam 3. Christianity

Family members
No. Name Age Sex Relation Marital Edu Occu Income
(yr) with status Per
head month
1.
2.
3.
4.
5.
6.
7.
8.
9.
10
Environmental sanitation

1. Kutcha
10. Type of house 2. Pucca
3. Semi-pucca
11. No. of living rooms
1. Present
12. Overcrowding
2. Absent
1. Adequate
13. Ventilation
2. Inadequate
1. Adequate
14. Lighting
2. Inadequate
1. Separate room
2. Within a room used for other
15. Kitchen location
purpose
3. Outside the house
1. Smokeless
16. Kitchen type
2. Smoky
1. Present within house
17. Bathroom 2. Present outside house
3. Absent
1. Present and using
18. Sanitary latrine 2. Present but not using
3. Absent
1. Proper
19. Drainage
2. Improper
1. Hand pump within house
2. Public hand pump
3. Municipal pipe in house
4. Public tap
5. Well within house
20. Source of drinking water 6. Public well
7. Pond
8. Mineral/RO water bought from
shops in cans
9. Tube well within house
10. Others:
 Maternal health (fill only for married women in 15-45 years age group who have been pregnant in the last five years)

Name Age at No. of No. of Whether TT Whether IFA Place of delivery Last Present status of
marriage pregnancies children taken during taken during last of last pregnancy pregnancy last child born
in last 5 years born in last pregnancy outcome alive
(including last 5 pregnancy (approx.. 100
abortions) years tablets)

1 1. Yes 1. Yes 1. Hospital 1. Alive 1. Alive

2. No 2. No 2. Home 2. Stillbirth 2. Dead
3. Aborted
2 1. Yes 1. Yes 1. Hosp 1. Alive 1. Alive
2. No 2. No 2. Home 2. Stillbirth 2. Dead
3. Aborted
3
4
5

Currently pregnant women (fill only if there is a currently pregnant women in the house)

Registered or not so far? No. IFA received so far Choice of delivery

Name Which trimester? of visits TT1 TT2 TT Booster or not place

1 First Yes Yes Yes Yes Yes Home

Second No No No No No Govt.
Third Pvt.
2
3

3
Child feeding practices (fill only for children below 2 years)
No. Name Age Prelacteal Type of Breast feeding Type of weaning food
(mo) feed prelacteal feed Initiation time EBF time When stopped given at start
given (hours after (mo) completely (mo)
birth)
1 1. Given 1. Sugar water 99. Not at all 99. Not at all 99. Not at all 99. Not yet started
2. Not 2. Honey given given given 1. animal milk
given 3. Animal milk 1. <30 min 2. rice
4. Holy water 2. 30 min-1hr 1. <6 months 1. <6 months 3. dal
5. 3. 1-4hr 2. >6 months 2. 6 mo-1 yr 4. vegetable
4. >4hr 3. > 1 year 5. kichdi
6. cerelac, nestum,
lactogen, milk powder
7. others

Immunization (fill only for children aged 12 to 24 months at present)

Whether immunization BCG, OPV OPV, Pentavalent Reasons: If any vaccine
No. Name Measles
card present 0 dose 1 2 3 is not given
1. Yes 1. Yes 1. Yes 1. Yes 1. Yes 1. Yes
1
2. No 2. No 2. No 2. No 2. No 2. No
2

4
Health care utilization

1. We don’t go anywhere, prefer home remedy

When some one in your family falls sick, where do you go 2. Local healer
No. 3. Govt. hospital
for treatment? (Write the most common option)
4. Pvt. qualified doctor
1. Known to us
2. Comfortable
1 Reasons for preferring this option (only for options 2,3,4) 3. Cheap
4. Recommended by friends or relatives
5. Others

Diabetes and Hypertension

Whether currently What type of

No. Name What disease? Regularity of treatment
taking treatment? treatment?
1. HTN 1. Allopathic
1. Yes 1. Regular
1 2. Diabetes 2. Alternative medicine
2. No 2. Irregular
3. Both 3. Both
2
3