1.

Name of the Respondent :

2. Address :
3. Religion :
4. Caste
5. Particulars of Family Members in the Household (Starting from the
Respondent) :
S.No Name Relt. to Sex Age Marita Edu. Occup. Monthly
. Resp. l Status Status Status Income
(Rs.)
1
2
3
4
5
6
7
8

6. Type of House : Hut / Kutcha / Puca

7. No. of Living Rooms : __________________________
8. Ownership of House : Rented / Own (Person with
Rela.)________/Others (Specify) ___________________
9. Drinking Water Facility : Community Well / Own well / Street tap /
Own tap / Streams / Ponds / Other ______________________
10. Bath Room Facility : No / Yes - Separate Room / Other
(Specify)__________________________
11. Toilet Facility : No / Yes - Separate outside house / Inside house
12. Cooking Fuel : Firewood / Kerosene / Cooking Gas / Other
(Specify) ________________
13. Electrifications : No / Yes
14. Availability of the following Household Goods :
S.No. Name of Household Good Availability (Yes / No)

1
 1 Bicycle
2 Fans
3 T.V.
4 Scooter / Motor Cycle
5 Fridge
6 Sofa / Dining Table
7 Telephone
8 Motor cars / Lorry / Truck

15. Details of the Living Children and Siblings :

S.No. Name Sex Age Marital Edu. Occupa. Income Place
Status Status Status (in Rs.) of
Stay
1
2
3
4
5
6
7

16. Did you have any of the following psychological problems and who
would help in that case ?
Psychological Problem No / Yes
Loneliness
Anxiety
Fear of Dependence
Depression
Fear
Stress
Lack of Self Confidence
Any Other (Specify)

Health Condition :
17. Respondents suffering / not with any chronic diseases and related
issues :

2
 Name of Diseases Yes / No How Long ? Types of
Treatment
Poor Vision / Cataract
Lung Problem / Asthma
Diabetes
Blood Pressure
Ulcer or Gastric Problem
Rheumatism / Arthritis
Heart Disease
Nervous disorders
Skin diseases
Kidney trouble
Tuberculosis
Back Pain / Slipped Disc
Dental Problems
Frailty / General
Weakness
Any Other (specify)

18. Do you require another person's assistance for the following and if
so, who is helping ?
Activities No Need / Need If Need, Who Helped
Help / Helping
Get out of the bed
Go to toilet
Bathing
Walk inside the house
Walk for some distance
To take food
Dressing
Combing hair
Boarding train / bus