Sy NUR SL STITUTE

Community Health Nursing

SURVEY PROFORMA

Name of the investigator:

Date of survey:

General information:

Name of the area

.District/ ward- Folder No
House No-
Address
Name of the head of the family
Religion
.Caste-SC/ST/General /OBC
extended
Type of the family- Nuclear /joint/
Size of the family (no. of family members)
Language for communication:
Basic information of family:
MaritalEducation Occupation Income Health Remarks
SI Name Relation Age Sex
status
with HOD of status
nu.

the family

Total income per month (Rs.):

1000 1000-2000 2001-3000 3001-4000 >4000

Environmental conditions:

Type of house- pacca/ semi pacca / kancha/ others.

2 3 >3
No. of rooms- 1.
Adequate inadequate.
Occupancy: Rent/ own
.Housing Floor: Damp proof >yes / no
 Root <10 t . > 10 t.

Windows area in relation to floor area

Urban<1/5 >1/s
Rural<10%/> 10%

Floor space (sq. n.): i) 50-70.

ii) 71-90. ii) 91-100. iv)>100.
House with courtyard: yes / no.

Light: 1. Natural light- adequate / inadequate.

2. Source light- clectricity/ gas lamp/ oil lamp.
of artificial
Ventilation: Adequate/ inadequate / no ventilation.
Cross ventilation: present/ absent.
Water supply: i) tap / hand pump iü) well ii)open tank / pond iv) pond & tube well
Kitchen: Separate corner of room/ veranda.
Type ofchulah: smokeless/ smoke forming
Space: adequate inadequate
Fuel used: gas / electricity / kerosene/ wood/ coal
Hand washing facilities: present absent
Storage of cooked food: covered/ uncovered
Any other observations:
Bathing and washing facilities: yes / no
Lavatory: Own / Public / open field defecation
Drainage: open/ closed soakage pit / kitchen garden
Waste disposal: dumping composing / buming / burring / throwing in open space
Domestic animal: yes. 0o..
Cattle shed: within house/ outside the house.
Surrounding
Mosquitoes house fly / presence of stray dogs / cat
Any accident prone enviropment in the surround ing.
Housekeeping: good/ not good.

Transport:
O w n : Tempo / trolley.

Private use: bus / mini bus train rolley/ auto / rickshaw.

Communication: TV/ radio / news paper / telephone / telegram/ post.

Dietary pattern:
No. ofmeals per day-12/3/ more
Consumption of fast food- Rarely / sometimes/ frequently / regularly.
.Food items
includedt in major menu: Mixed diet/ only staple food.
 * * * * * * R

Health seeking behaviour

Regular physical check up Yes /No

Health facilities avail- Hospital/ PHC/
Sub centre / Private / NGO/ Local vaidya.
Decision maker during crisis: Husband/ wife / mother-in-law /
father-in-law /
others
Health assessment:

Immunization status of < 5 year children

LLLLLILLLLLI
Disease condition: If there is any case of ilIness

SI.No. Name
Age Disease Ireatment Remarks

Maternal health status: (family planning practices)

ah Health status in
prCgnaney
 Heaith satus of
lactating tnother (have chid within one year

Vital events in
femily for lax one year
Birth

*ane Date Phace of detiver Devered b Birth wt Birth Pamarks

berth Ppietratios
Hose lastitutiva strised TBA Miw 25 5 y

Mariage
ame of the couple Ag (yT) esration Remerks
Mac femae Yes No
22<112

Death

Caue of death
Registration Remarks
Yes No

In aition to t e above. utens enpeced to obrain

are
foilowing information.
Descripticn of community. location. of chool, o. of health
o.
ship. and amy csther relevart
care
agencies, place of
information related to beaith.
2 Lis the varget cupie with ceais in
riority wise.
Vaiain rad to beaith charn n iertity te dezer of malnutrition for < S yrs. Children
4. Prepare farnily care plan using the forma