7 '\

;
~

..,
._____.
,-

FAMILY HEALTH STUDY

Date of study:
Name of the students:
Name of the Head of
the Family:
Address:

Urban (non slum) /Urban (Slum) /Rural (Village:

,- FAMILY PROFILE
Family Structure

.Q- C ~ i
..C C O U)
'"' rn LL O ·- c
~ C Q _ i< ·. ;:; CO ig0 0
>- .Q I ca rn ca a. o :E
SI. No. Name -a.> x ~
- ..c - co
-~ ::J
:::,() ::J
o ~
·- "O
c
Ol Ql Ql .t:: - "O O O
<!. Cl) 0:3: ~(/) w O ~()

HOF
I

'

*Marital status: Married, unmarried, widow/widower. Separated

**Medicosocial conditions
• Physiological conditions: Infant, under-five child, pregnancy, lactation, old age
• Medical conditions: Hypertension, Diabetes, Any chronic Disease like TB, Asthma, Cancer, etc
• Social conditions: Disability, mental retardation, psychiatric conditions, alcoholic, unwed pregnancy

51

,-

~
.J
 '<ET
I~

• Number of children(< 15 yr) : _ _ _ _ __

• Number of geriatrics (> 65 yr) :_ _ _ _ _ __

• Dependency Ratio
Persons < 15 yr + > 65 yr : Persons 15-64 yr = ___________

• Family type:
Nuclear/Joint/Three generation : _ _ _ _ _ __
Total members : _ _ _ _ _ __

Vital Events in the Family

V'ttal events during last one year Relevant details

~
Births : Yes / No Sex
Place of delivery
Deaths : Yes / No Age
Sex
Cause of death
Place of death
Marriage : Yes / No Age of male
Age of female at marriage -
Divorce: Yes / No
Adoption : Yes / No
Details of any diseases requiring hospitalization / any surgery:
1.
2.
3.

SOCIOECONOMICAL STATUS ASSESSMENT

Religion: Hindu / Muslim / Christian / Others, specify

Caste
Occupational Status of the Family
Nature of occupation
Professional / Semi-Professional / Clerical -
_,
Shop owner Farmer / Skilled worker / Unskilled
worker / unemployed.

52
 Monthly expenditure of the family on: Rs.
,,
Food-
Fuel=
Clothing=
Education=
Electricity =
Housing (renV maintenance / taxes) =
Social functions (marriages, festivals) =
Health and Illness =
Travel / Transport =
Recreation =
Anv other exoenditure =
.,
Economic strata BPL* APL I Don't Know
(White ration card holders can be roughly classified as Below Poverty Line)
Monthly income of the family:

Per Capifa Monthly Income = Total family income

Total Family Members
Balance:
Balance of income over expenditure:
Socioeconomic class:
I
+ I - Rs.

The family belongs to class, according to

classification.
(Use either modified BG Prasad/ modified Kuppuswamy / Udai Pareek classification)
Utilization of social security schemes
Old age pension NA/Yes/ No
Widow pension NA/Yes/ No
Differently-abled pension NA/Yes/ No
A.1y other, specify NA/Yes/ No
Health Insurance
Government Aroavasri / EHS / CGHS / ESIC
Private, specify
Utilization of social services
Health
PDS (Public Distribution System) / Ration
Anganwadi
Social Problems
Any unemployed member in the family:
Addictions:
Any mother who is unmarried, divorced or
abandoned by husband's family?
Any handicapped or chronically ill family member?
 ..~. ·. ~~ ·
~
1r ~ . ,.."', . _- ~'!.~
~- . >=- ..,_.-- W

-~;,,l~\\ ·. .
(~ -

'

.,
Any children above 5 years age not going to
school. If yes, give reasons.
Is the mother of under 5 yrs child working
anywhere? If so who looks after the children
during her absence.
I

Any other (specify)

-
• I

LIVING ENVIRONMENT
Physical Environment (Housing)
'·.f r4
House is a dwelling structure used by man for settlement, which provides physical, ~
mental and social health needs of an individual and of the family \
Perimeter of the house Well protected I Easy entry for stray animals l -~
Locality of house
Environmental pollution
Congested / Non-congested area
Air, noise, toxic fumes , odor, dust, others
l
~ ? ~
Environmental disturbances Weather inclemency, moistu re, open drain, others ~

\
Connectivity Road, School, hospital, socia l, cultural, recreational places, etc ~
,,.
House I

Ownership Own I Rented

Attachment Side to side/Back to back/Both
Set back Adequate/Inadequate/Nil .,
.------
Construction
Type of house Katcha / Semi Pakka / Pakka
--,
Roof RCC/Tile/Zinc sheeVThatched/Other
Floor Mud/CemenVStone/Others, specify ~ - /I/IC(,WI W10-.l.
Walls Mud/Brick/Cement/Stone/Others, specify
Construction safety Yes/No ·. t.,(C:Bf- f\\re ~ 11(1'..
No of living rooms Adequate/Inadequate -:.r ~ i ~ e!l- ,}-f"!
Total area of the living rooms ;r-ta ~dt'.zrtO'
(floor area):
Per capita floor area:
Comment on overcrowding
Doors and windows space SufficienVlnsufficient
LiahtinQ SufficienVI nsufficient
Ventilation SufficienVlnsufficient
Cross ventilation PresenVAbsent _,
Dampness PresenVAbsent

k ~
~teYes/No
54

~
la~
IM>J
r. "1·
~ 1!'a
 ;- ~ ~ r
.---.,1! ~~
.---~
~'{~t!i~- -.
_
~, ~
~ ~ --.,#
.-
\t:.e- -
I_,•t
.. , ~~ ~ ._.-, ~_· _' J '- . ~/l""'f'r~ ' ·,

--- .JildJt
'4•. ~-•en.
~ --

,~
""'i.1
!ta.
~
ttll
~ J
~~
Space Spacious/Congested
Light Adequate/Inadequate

~
VenlllatlQA Adequate/Inadequate
Fuel used Wood/Coal/Gas/Cow dung cakes/Others
Chullah used NA / Smokeless/Smoke letting
Smoke ventilation Present/Absent
Storage of raw and cooked food Hygienic/Unhygienic '-41

~~
Wat er Supply
S.Jurcos of water:
Drinking purpose : Tube well / public tap / domestic tap / Tanker /

~~~
Bottled water / Others, specify
Cooking purpose : Tube well / public tap/ domestic tap/ Tanker/

---- Bottled water / Others, specify

(\;\~ ·
Washing - bathing purpose: Tube well / public tap/ domestic tap/ Tanker/ ~ \
I

~
Bottled water/ Others, specify
Distance of drinking water source km
Duration of supply : Continuous/ Intermittent
Adequady of supply of water: Adequate / Inadequate
Pollution at Source : Present/ Absent
Purification of water at source: Done I Not done / Don't know
(based on ch lorine smell)
Is drinking water given any special treatment at household level (like boiling, filtration
at home, chlorination at home, etc.)? Yes/ No
If yes, specify
Water storage and handling. Hygienic/ Unhygienic
Wa ste Disposal
Disposal of refuse: Throwing indiscriminately/ common pit/ collected in a container / burning /
composting / municipal service
Latrin e Present/ Absent
Latrine Usage All / Some except children / None
Drainage; Open drain/ Closed drain / Underground drainage
Biological Environment
Cockroacbes, rat problem Present/Absent
Snakes, scorpion Present/Absent

~.
Mosquitoes, flies, Breading Places Present/ Absent
Domestic Animal/Pets Yes/ No ~
If Yes, Specify
Maintenance of cattle shed
Cleanliness of premises
Hygienic/Unhygienic
Clean/Unclean

55
,.
~

•
~

I•·
. ~7
,,

Water collection/ Flies and mosquitoes breeding/

Surroundings of house
Children Open defecation / Street dogs/ Poultry/ <
Pigs / Rats / Others
~

Psychosocial Environment
How many hours they generally spend for seeing lV programmes
in a day? -
What is their favorite pastime or recreation together as a family? .. ,
For last 6 months, how frequently, they had vacation?
For last 6 months have you attended any family functions like gettogether,
attending marriages, festivals like Bonalu etc?
I
Do you feel that everything is going on well and you are satisfied
with the present events?

CULTURAL PRACTICES
Family Cultural Practices
Practices Details of practice
Concept of Disease Cause
Concept of cure
Oral hygiene (Brushing)
TaJ<lng bath regularly
Oil bath anytime during the year & how often
.. ,
Expos ure to sun
Washing hands Before eating (with soap)
Sharing towel, soap, brush, bedding
I
Field defecation I
Sleeping in open without using mosquito nets
Whether fingers are dipped in water while collecting
water for drinking
Storing the water for domestic purposes in drums
without lid.
Consanguineous marriage
Whether any children not using latrine
wearing washed cloths
Yes/No; How
Washing bedsheets regularly
often?
Using sanitary napkins during periods*
"Shall be asked by female Medico, if gents are not present nearby.
~

KNOWLEDGE AND PRACTICE ON HEALTH & UTILIZATION OF HEALTH

SERVICES

Knowledge regarding causation, modes of prevention and care seeking

behavior ..with respect to the following diseases:
(Discuss with adult family members and comment on the following)
Diarrhoea:

Malaria:

Tuberculosis:

Leprosy:

I._

Any other disease which the family feels to be important:

Knowledge and practice towards:

(Discuss with adult family members and comment on the following)
Infant feeding practices:

- Importance of colostrum and

exclusive breast-feeding
Duration of exclusive breast
I._
feeding
Time of weaning
Feeding during illness
 ~
i
~- Ill-·
~fl, ~,& vi-,·
Antenatal, natal and postnatal care: ~'t>"' ~ ~e.'t> -~
Importance of regular check-ups
~o ; ~or,; 'b'\)1;,v-~"'-"~
i's~ ~!?)\ ,.\c;0~ ~"~ - 't>f,j'
Safe delivery practices ~o '/:,..~,$,, _{00 >-<t
Iron, Folic acid prophylaxls ~~
Diet, rest and TT
Immunization:
Common vaccine preventable diseases
Importance of Immunization
Contraception and famlly planning:
Ideal age of marriage and age at
pregnancy
Interval between pregnancies
Number of children
Family planning methods - temporary
and permanent

Utilization and practice of preventive reproductive health services

(If there are eligible couples i.e., currently married women in 15 to 45 years age group
and staying with their husbands)
Serial No of women in the family
Age at marriage (years)
Consanguineous marriage (Yes/ No)
Age at first pregnancy (years)
Total number of live births _,
Total number of abortions or still-births
Total number of current living Boys
children Girls
Interval between last two deliveries
Birth spacing/ limiting methods if currently
using, specify
Reasons for non-utilization /
discontinuation of family planning
methods (if any):
8
o\O e.t:;i
;,'t>,p,. .s\~1,
~cono\\<
,s, e;

58
 \.

I
Utilization of following services during pregnancy within last 1 year I

I Number of Antenatal visits

Tetanus Toxoid doses ( 0 I 1 / 2 / Booster)
Iron and folic acid tablets consumed (specify number)
Diet (Increased I Same I Decreased)
Regarding delivery:
Place of,~delivery:
(Home I Hospital / Other, specify)
Delivery conducted by:
(Health personnel I Trained Dai / Other specify) '
I

Utilization and practice of preventive child health services

(ff there are children less than 5 years of age)
I
Serial No. of under 5 child
Aoe of the child in months
Colostrum given (Yes/ No)
Prelacteal feed given (Yes/ No)
Exclusively breast-fed (Yes/ No)
If yes, duration of exclusive breast feeding in months
Age at which weaning started
Growth monitoring regularly done (Yes I No)
Beneficiary of Anganwadi/ ICDS (Yes I No) I I
Child's lrpmunization status
(Verify from Immunization card if available, otherwise record from history)
Serial No. of under 5 child I

OPV (0, 1, 2, 3, Booster dose)

Hepatitis B (Birth dose)
BCG
Pentavac / DPT (1,2,3 dose, DPT booster)
Rotavirus vaccine (1,2,3 dose)
IPV (1, 2 dose)
Measles (1, 2)
Vitamin A syrup ( 1 - 9 doses)
Comment on Immunization status:
Fully Immunized /
Partially Immunized/
Unimmunized
Reasons.for non-immunization/ partial immunization (if any)

59
Home Visit by any health care provider: ASHA / Anganwadi Worker/ ANM / MPHA-F /
MPHA - M / Urban malaria team / NGOs / Medical Officer / Others, specify

Treatment Seeking Priority (Rank in 1 to 8)

Traditional healer Home remedies

Private clinic and hospital Going to temple
Primary health care system Self medication
Ayurveda, homeopathy and other Drug store
indigenous health system

60
 ,~

DIETARY ASSESSMENT

Food Practices
Food Habits: Vegetarian /Non-vegetarian /Mixed diet
Meal pattern: Regular/ Irregular

Morning Breakfast Lunch Evening Dinner Bedtime

.~ Tea/Coffee Tea/
Coffee
Mllk./Otller
IJeverago
Regular
Irregular

Diet Survey (By 24 hour recall - oral questionnaire method - RAW FOODS)

Table 1
-
Food group Food items Quantity Total family consumption
(specify) consumed per day of food group per day (gm)
(gm)
Cereals & Millets

Pulses

Eggs .~
Flesh foods

Green Leafy

Vegetables

Roots and Tubers

Other vegetables

Fruits

Milk and milk products

Oil and fat

Sugar and jaggery

61
 f
I 0~
~,o~ .
~o~''b> ,(,.$'Q
c"
~·

Table 2 - Reference values based on NIN Dietary Guidelines for Indians

Energy & Nutrients available (per 100 gm)

ood group IEnergy Protein Carbohydrate I Fat (gm)
(Kea~ (gm) (gm)
Cereals & Millets 334 10 67 2.7
Pulses 334 20 , 50 2.3
Eggs 170 14 - 14
Fiesh foods 200 18 - 14
Green leafy 46 3.6 - 0.4
Vegetables
Roots and Tubers 80 1.3 18
Other vegetables 28 1.7 - I 0.2
Fruits 40 - 10
Milk and milk products 70 3 5 I 3
Oil and fat 9/gm
Sugar and jaggery 4/gm

Table 3 - Estimation of actual Energy and nutrients intake

Nutrients available
Food group Family Energy Protein Carbohyd rate Fat (gm)
Consumption per (Kcal) (gm) . (gm)
day (g m)
Cereals & Millets
Pulse
Eggs
Flesh foods
~·
w
Green Leafy 2)
(l)
X
Vegetables Ol Cll
1 ~ (./)
Roots an d Tubers
Other vegetables HOF
Fruits
MiJk and milk products
Oil and fat
Sugar and jaggery
Total

"' 50 g of Flesh foods/egg = 30 g of Pulses

62

lower. Separa ted

: htld , pregnancy. tac

l
Any chronic 0 1s00s,
,on, psycl11atnc cond1
 Calculation of Energy Consumption Unrt (CU) for the Family
Table 4 - Consumption Units for the Family

i:amity member Sex Occupational activities GU X Number of persons

Adults Male Sedentary 1 X =
Male Moderate i.2 X =
Male Heavy i .6 X =
Female Sedentary X
0.8 =
Female Moderate 0.9 X =
Children
- Female Heavy 1.2 X =
Age group
i-3 years 0.4 X =
Q >,
3-5 years "80 ~- 0.5 X =
O> t,
~7 years o.: : 0.6 X =
7-9 years ~~
;;:: ., 0.7 X =
tJ >,
Q J:.
9-12 years a. a
e~ 0.8 X =
12-21 years .!:: "' 1.0 X =
Total consumptjon units of the family (fCU) is
1 Consumption Unit = 2400 KcaVday

Calculation of Nutrient Requirements

Energy requirement of family (E) = Family TCU units x 2400 Kcal
= Kcal

Table 5 - Calculation of Nutrient requirement for the Family

Nutrient Percentage of total energy required Requirement 0n gm)

Protein 15% x E = ➔El'flO EP00/4 =

1
~arbohydrate 65%xE= ➔ Ea.+o Y4 =
t:at 20%xE= ➔ Ef'AT ~1'9=

Note: a) 1 gm of protein provides: 4 Kcal

b) i gm of fat provides: 9 Kcal
c) 1 gm of carbohydrate provides: 4 Kcal

63
 Assessment of Adequacy of Dietary Intakes

Balanced diet Requirement I

Fam ily Consumption Quantification
for 1 CU Required Actual Deficient ' Excess
(R) (Rx TCU) (A)
Cereals & millets 375 g
Pulses 75g
Flesh foods*
Green Leafy Vegetables 100 g
{GLV)

Roots and Tubers 2009

-,
Other Vegetables 200g
Fruits 100 g
Milk and milk products 300ml
Oil and fat 25g

Sugar and jaggery 20g

* 50 g of Flesh foods/egg = 30 g of Pulses

Nutrients Family requirement ROI Family Consumption Quantification

Deficient Excess

~ Protein
• Carbohydrate
;, Fat
-
,. Energy

Inference:

Advice :

64
 fEl'T ~EEOS Of 1\-\E fMJ\\L'I

\ \\ea\\\'\ nee~s
\ Free meo,ca\ seN,ces
\
\
l
Genera\ needs
Housing
--
\ Free aenta\ seN,ces \ Water --
\ Ca\arac\ cam?s \ "Toilet and drainage
-
\ S?ec\a\\s\ seN,ces \ Education tacilities
-
\ SeNices lluting l\1ghl
·a\"\O emergenc'/
\ t>rnbulanoo \lrans\)01\\ \
\ Fooo-fwai\abilit'j

Government benefits
seMces-
Others
\ Others \ 1

nc.R~mo~s
.. Fam\~ gmuµ o, µmsons re\ated b'f marriage, blood and adoption residing together and
sharmg common s'ne\\er, kitchen and property.
• ~PL- Pet da'J ca\orie intake oi a person < 2400 Kcal in rural area, 2100 Kcal in urban area
,?\ann,ng commission 01 \ndia) and per capita daily income < Rs 15 in rural area, < Rs 20 in
uroan arna. (_New µo\Jert,r \ine: Rs 32 in villages, Rs 47 in cities - RBI Governor Rangaraian
Committee Report)
• *Q\re{Crowding r\oor area o1 \i\Jing room < 50 sq tt/person l< 1 year is counted as O; 1-1 Oyear
as "\12) ,wo opposite sexes> 9 ')'ear not couple are obliged to sleep in the same room

Summa~ a\ \he Fam\\',' Hea\\h Study

"\ . Soctoeconomic status
2. Cu\\Ura\ practices
3. \j\l'\ng env\ronment
4 . ~utrmona\ status
5. Hea\tr.-pmn\e
6. \J\i\@oon o\ nealtn seNices
7 . 'f..N' regardin<;r. nealtn.
e. Felt nea\\n needs

).

ti

65