FAMILY PROFILE

[ COMPREHENSIVE FAMILY HEALTH RECORD ]

I – IDENTIFICATION INFORMATION
 House No. - ……………………….………..……………..
 Name of Street - ………………………………………………..
 Village - ………………………………...….…………..
 District - ……………………………………………..….
 State - ………………………………………….…….
 Name of the head of the family - …………………………………….………….
 Religion - ………………………………………….……..
II – FAMILY COMPOSITION AND CHARACTERISTICS
S.N. Name of the Age Sex Education Occupation Relationship Remark/
Member level with Health
Head of Family
Status

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
1. Description of family member

2. Type of Family - ...………………………………………….………

3. Economic status of family - ……………………………….……………..……..
Number of Earning Members - ………………………………………………...
 Total income of family - ……………………………………………..……...
 Other financial resource - …………………………………………….………
Head Items Amount % of Budget
Expenditure Food
Health
Clothing
Education
Housing (Rent)
Savings For future social
works/tasks for
unexpected expenditure

4. Means of Communication - …………………………….……………….

 Language of the family - ……………………….….…………………
 Communication facilities available - ……………………………………………….
……………………………………………….
5. Transportation facilities - ….………………………..…………………
…………………………...………………….
6. Nutritional Status - …………………………………….……….
 Eating Pattern - …………………………………………….
 Selection and Preparation - ……………………………………………..
 Staple food of the family - ……………………………………………..

III ENVIRONMENTAL ASSESSMENT

1. Housing - ……………………………………………..
 Built - ……………………………………………..
 Number of rooms in house - ……………………….……………………..
 Average size of rooms - ……………………………………………..
 Ventilation - ……………………………………………..
 Total area of house - ………………………………………………
2. Source of light - ……………………………………………...
3. Water Supply - ……………………………………………...
4. Kitchen
 Place - ……………………………………………...
 Sources of fuel - ……………………………………………..
 Kitchen garden - ………………………………………….......
5. Disposal System
 Excrete - ……………………………………………….
 Refuse - ………………………………………….........
 Sullage Water - ……………………….……………………….
 Pet animals - ……………………………………………….
IV HEALTH RISK AND HAZARDS

1. Physical Hazards - ………….…………………………………

2. Chemical Hazards
3. Habits
4. Flies/Insect/Rodents
5. Other Risks
V HEALTH AND ILLNESS HISTORY
1. Mother
 Pregnancy at present
 If Yes no. of pregnancy
 Duration of pregnancy
 TT Vaccination
 Anemia
 Any other information about
Maternal Health
 Children
No. of Children (M)
(F)
No. of Children under 5 years - ………………………………………………
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S.No. Name of Age Sex BCG OPV DPT MMR Vita A Any
Children Solution other
specify

I II III B I I III B
O I O
O O
S S
T T
E E
R R
1.

2.

3.

4.
 2. Family Planning
 Eligible Couple
 Users of Contraceptives
 Prefence of Contraceptive
 Willingness for perman
Starlization
3. Records of Vital statistics
4. Illness in family
 Illness, where family go for
Treatment
 Therapy followed
 If any member taking
Continue treatment
 If yes mention the medicine
 Details of members suffered
with communicable disease
- …………………………………………………
- ………………………………………………..
- ………………………………………………..
- ………………………………………………..
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- ……………………………………………….
- ……………………………………………….
- ……………….………………………………
- ….……………………………………………
- ………………………………………………..

5. Present health of the family members - ……………………………………………..

6. Health Resources
 Health agencies - ……………………………………………..
 Sources of Health Care providers - ……………………………………………..
 Voulantry Health agencies or
NGOs of Health Care Sector - ……………………………………………...
Utilization of Health care -
agencies by family ……………………………………………...

VI IDENTIFICATION OF HEALTH PROBLEMS

1-

2-

3-

4-

5-