RASHID LATIF MEDICAL COLLEGE, LAHORE

Community Oriented Training Program for Undergraduate Students

HOUSEHOLD SURVEY PROFORMA
Name of Surveyor __________________________________ Class ___________________ Roll No.____________
Batch ______________________________Serial No. ____________________ Date _____________________
Name of Interviewee ____________________________________________ Religion _______________________
Locality/Address ______________________________________________________________________________
1.(a).
Age at
Present Occupation Monthly
Name First Education
Age * Income
Marriage
Head of
Family
Husban
d
Wife
In case of second marriage record age at first marriage.

b). OTHER FAMILY MEMBERS (write in chronological order)

Relationship
Occupation Monthly
Name Age Sex With the Head Education
* Income
of the Family

2.
Type of family: Nuclear Extended
Family members: Male_____________ Female ______________ Total_________________
Total No. of children under five years: ________________
Total number of working members:_________________
Total family income/month: Rs. _____________________
Income percapita / month: Rs. _____________________
____________________________________________________________________________________________

* Classify occupation under one of the following groups:

Farmer, Laborer, Businessman, Employee (Govt./Private), House wife, Student, None.
3. Vaccination status of children upto “2” years of age according to the EPI Program (if applicable):

Sr. Name Age Sex BC Polio (OPV) IPV Pentavalent Pneumococca Rota Measle V. Card
No G (DPT+HepB+Hib) l vaccin s available
. vaccine e vaccine
0 I I II I II III I II III I II I II Ye No
I I s
1
2
3
4
5

 If vaccination card is available;note down the dates on card in respective columns.

4. LIVE BIRTH LAST YEAR:

[ ] No [ ] Yes
If yes sex of new born baby: Male _________________ Female ___________________

5. DEATH LAST YEAR:

[ ] No [ ] Yes
If yes age at death ______________________ Sex ____________________________
Cause of death (if known) ____________________________________________________
6. a). HOUSING
Kacha [ ] Pucca [ ] Mixed [ ]
b). No. of living rooms in the house _________________________________________
c). Animal kept Yes[ ] No [ ]
d). Place where kept Within House [ ] Outside House [ ]
e). If yes, type of animals kept:
Domestic Animals [ ] Number [ ]
Pet Animals [ ] Number [ ]
f). Amenities within the house:
TOILETS WATER SUPPLY ELECTRICITY SUI GAS
[ ] Available [ ] No [ ] No [ ] No
[ ] Not Available [ ] Yes [ ] Yes [ ] Yes
If not available
If yes
[ ] Use of Field
[ ] Well
[ ] Public Latrine
[ ] Hand Pump
If available [ ] Electric Pump
[ ] WC/Pit Toilet [ ] Community Supply
Sewer (Water Carriage)
[ ] Own Arrangement
[ ] Community supply
 7. Number of family members having following illnesses: (The disease should be diagnosed by
a qualified doctor):
No. Disease No. of Family member affected Sex
1. Diabetes Mellitus
2. Hypertension
3. Coronary Heart Disease
4. Pulmonary Tuberculosis
5. Hepatitis:
 B
 C
 Others (specify) --------------------------
6. Scabies

8. a). Preference for utilization of available health facilities:

QUACK/
PRIVATE PRIVATE HOMEOP SPIRITUAL
GOVERNMENT HAKIM OTHERMED.
HOSPITAL DOCTOR ATH Healer
PRACTITIONER
CHW / BHU/ RHC DHQ/THQ Teaching
LHW MCH Hospital Hospital
center

b). Reasons for not utilizing Government health facility (if available)

[ ] Unsatisfactory care [ ] Insufficient care

[ ] Costly [ ] Distant
[ ] No information of health care facility [ ] UnsatisfactoryStaff behavior
[ ] Any other reason (Specify): ___________________________________________________