COMMUNITY HEALTH NURSING

FORMAT OF SURVEY OF FAMILIES

1. Name of the Area: Rural /Urban…………………….

2. Name of the Health Centre…………………………….
3. Name of the Head of the family…………………………
4. Type of Family: i) Single………………….……ii) Joint…………...................
5. Religion: i) Hindu ……………………..(Specify the Subcaste )
……………….
ii) Muslim……………………..(“)…………………………………
iii) Christian…………………...(“)…………………………………
iv) Any other…………………..(“)…………………………………
6. HOUSE CONDITION:
I) Type of House :
i) Pu c ch
cc c a
a a
ii) Semi iii) K
pu ut
II) Rooms:
i) Nu ii) Adeq iii) Inadeq
mb u uat
er at e
e
III) Occupancy:
i) Te ii) Owne iii) Mo
na r nthl
nt y
rent
IV) Ventilation:
i) A u
d Inadequate
a
e t
q No ventilation
e
V) Lighting
i) El it ii) Gas
ect y La
ric mp
 iii) Oil m
La p
VI) Water supply:
i) Tap/ ii) Well
Handpum iii) Open tank
VII) Kitchen:
i) Se ii) Corner of iii) Varand
par the a
ate room
VIII) Drainage:
i) Ad ii) Inade iii) No
eq q dra
uat u ina
e at ge
e
IX) Lavatory:
i) Own iii) Open fectio
Latrine air n
ii) Public de
latrine

7. FAMILY COMPOSITION:

S. Name Relationship Age Sex Education Occupation Income

No. with head
1.

2.

3.

7A. Total Income of Family 7B. Education Status

Number
a) Below 500 a) Not literate
…………..
b) 500-1000 b) Primary education
…………..
c) 1000-1500 c) Middle School
…………..
d) 1500-2000 d) High School
………….
 e) 2000-and above e) PUC and above
…………..
8. TRANSPORT AND COMMUNICATION MEDIA:
I. Transport II: Media
1) Transport 1) Telephone
2) Owns Tempo/Tractor 2) Television
3) Uses B.T.S. / KSRTC 3) Radio
4) Uses Private Buses 4) Newspaper/
Magazine
5) Train 5) Post and
Telegraph
III. Language IV. Language
Known
1) Mother Tongue 1) Kannada
Read/write/speak
2) Kannada 2) English
Read/write/speak
3) Hindi 3)Hindi
Read/write/speak
4) Tamil/Telgu 4) Specify Others
Read/write/speak
5) Malayalam/ Marathi
9. DIETARY PATTERN:
Food Preparation and storage
Foods Available Foods used Traditional Ideal Unhygienic
Rice
Ragi
Jawar
Wheat
Vegetable
Fish
Meat
Egg
Milk and Milk product
Pulses
Tubers

10. STATEMENT OF EXPENDITURE OF THE FAMILY :

Sl No. Item Amount spent (Approx) Percentage of Total Expenditu
1 Food
2 Clothing
3 Housing (Rent)
4 Medicine
5 Children Education
6 Recreation (Movies etc)
 7 Smoking and / or liquor
8 Debt
9 Saving
10 Other (Specify)

11. IS THERE ANY CASE OF FEVER –(IF YES, WRITE

NAME, AGE, TREATMENT AND REMARKS)
1. with rigors ?
2. with cough?
3. with rash?
Sl No. Name Age Disease Treatment Remarks
1.
2.
3.

12. DOSE ANYONE HAVE SKIN DISEASE (E.G. ITCHING,

PATCH, RASH) ?
Sl No. Name Age Disease Treatment Remarks
1.
2.
3.

13. DOES ANYONE HAVE A COUGH FOR MORE THAN

TWO WEEKS?
Sl No. Name Age Disease Treatment Remarks
1.
2.
3.

14. DOES ANYONE HAVE ANY OTHER ILLNESS?

( CHIKUNGUNYA, HIV, STI, OR ANY OTHER)
Sl No. Name Age Disease Treatment Remarks
4.
5.
6.

15. IS ANY WOMAN PREGNANT? IF YEA, WRITE THE

FOLLOWING REMARKS:
1. Specify gravida
2. has she been registered
3. is she getting
Sl No. Name (s) 1 2 3 4
1.
2.
3.
 16. HAVE THERE BEEN ANY ( WITHIN YEAR –VITAL
STATIC’S)
1. Birth?
Sl No. Name Age Disease Treatment Remarks
1.
2.
3.

2. Deaths?
Sl No. Name Age Disease Treatment Remarks
7.
8.
9.

3. Marriages?
Sl No. Name Age Disease Treatment Remarks
10.
11.
12.

17. ARE THERE ANY CHILDREN BELOW FIVE YEARS

WHO HAVE NOT RECEIVED IMMUNISATION?
(Specify name, age, reason for not being immunised in remarks)
1. BCG vaccination
2. DPT Vaccination
3. Poliomyelitis vaccination
4. Measle vaccination
5. Vitamin A solution

Sl Name Age Sex 17.1 17.2 17.3 17.4 17

No. 1 2 3
1.

2.

3.

4.

5.
 Remarks………………….
18. IS THERE ANY ELIGIBLE COUPLE: (IF SO LIST
THEM ON PRIORITY)

S.No. Name Age Sex I (Priority) II(Priority) PS SS EM

1.

2.

3.

4.

PS= Primary sterility

SS= Secondary sterility
EM= Early menopause
1. Using a contraceptivernethod ? if yes, specify
2. Intending to undergo: i. vasectomy ii Tubal
Ligation
3. Not interested to adopt FP method (state the reason)
………………………………………………………………………
………………………………

19. IS THERE ANY CHILD 0-5 YEARS IN FAMILY WHO

SHOWS SIGNS OF MALNUTRITION?
1. Kwashiorkor?
2. Marasmus?
3. Vitamin A deficiency?
4. Anaemia/
5. Rickets?
S. No. Name Age 19.1 19.2 19.3 19.4 19.5
1.

2.

3.

4.

5.

6.
Remarks ……………….

20. IS THE SULLAGE WATER BEING DISPOSED OF

HYGIENICALLY? IF YES TICK ANYONE/ALL
1. drain 2.Soakpit
3.Kitchen Garden
if no, state reasons
……………………………………………………………………
……….

21. IS THE RUBBISH BEING DISPOSED

HYGIENICALLY? IF YES TICK ANYONE/ALL
1. Composing 2. Burning 3.
Burying
if no, state reasons
……………………………………………………………………
……….

22. IS THE EXCRETA BEING DISPOSED OFF

HYGIENICALLY? YES / NO
if no. state reasons.

23. ARE THE CATTLE AND POULTRY HOUSED

HYGIENICALLY?
1. Separate 2. Within house
State reasons
……………………………………………………………………
……………..

24. IS THERE A WELL OR HAND PUMP?

1. Is it maintained in good order? Yes/ NO, if No. state reasons.
2. When was the well chlorinated? (Date) if No, state reasons
for not chlorinating.

25. WHETHER HOUSE IS KEPT CLEAN? Yes / no. If no.

State reasons.

26. WHEN WAS THE HOUSE LAST SPRAYED? (DATE)

if no. State reasons.

27. IS THERE ANY BREEDING PLACE OF INSECTS

AND RODENTS? Yes /no.
 28. IS THERE ANY STRAY DOGS IN THE VICINITY?
Yes/no. If yes write.
Approximate number of dogs.

29. IF ANYONE FALLS ILL WHERE DO YOU GET

TREATMENT?
1. Hospital/primary health centre
2. sub-cemre primary health unit
3. Private nursing home
4. Indigenous doctor/Local Vaidya.

30. ARE OFFICIAL HEALTH AGENCIES SERVICES

ADEQUATE? YEA/ NO.
if no. state
reasons……………………………………………………………
………………………

Note : In addition to the above) students are expected to obtain following

information by observation and other methods.
1. Description of the community location, topography, climate history
etc. Type of government no. of schools no of health care agencies.
Balwadi or ICDS centres places of worship (e.g. Temple) and any
other relevant information related to health.
2. List of target couple with details on priority basis.
3. Maintain record of Road to Health Card for knowing the degree of
malnutrition for under 0-5s wherever necessary and use nutritional
assessment from promptly.
4. use problem solving approach/ construct good nursing care plan by
using” PRONE” format taught to you in recent” Community Nursing
Process’ lectures.
 5. Remarks can be written in separate sheets quoting code No. (e.g.
12.11 No sensation found on the patches needs referral and follow –
up services)

Date of Survey Name &

Signature of Student
 5. Remarks can be written in separate sheets quoting code No. (e.g.
12.11 No sensation found on the patches needs referral and follow –
up services)

Date of Survey Name &

Signature of Student