Scribd Logo
Upload

Welcome to Scribd!

  • d762aa215ef779b5bab5aace654458ac

    Uploaded by

    Mostaque Ahmed
    4 views5 pages

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    4 views5 pages

    d762aa215ef779b5bab5aace654458ac

    Uploaded by

    Mostaque Ahmed

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    of 5
    Form ID: Department of Community Medicine VMCH & RI, Madurai Family health survey General info T.__|Houseno./ EU no, 2.__| Street or areaname 3.__| Name of head of the family 4,__| Education ofthe head of the family_ 5. __ | Occupation ofthe head of the family 6.__| Total family income Rs, 7.__| Total no. of family members 8. ‘Type of the family 7. Nuclear 2. Extended 9. [ Religion of the family 1. Hindu 2.1slam__3, Christianity Family members No. Relation] Marital [Edu [Oceu 7 Income with status: Per head month a 7. 2-Currently married Diver ‘Widowed SsSeparated Decupation: (only for personsaged [and moray 1L-Still studying or student 2-Unemployed (nat stulying.not working Retired from work (for persons aged »60 years) Unsklled Semiskilled, 6:Skilled Codes: Bex Relation with head 1-Male, O-ttoad 2-Female L-Wife Z-Hhusband 3Son ‘Daughter 5-Son in aw 6-Daughter in awe TGrand children B-Other (uncle aunt.nephew, niece etc.) arial statis: Tiueation: L-Newer married 1-Nat yet started school 2-Stil studying, No formal schooling butean read and write ‘Completed primary school (1-5 std) 5-Comipleted middle school (6-8 te) 6-Completed secondary school (9-10 td) T-Compleved higher secondary school (11-12 std) 8-Completed diploma 9-Complated collage degree Income: Ask abouttheusualineame per mont ‘Addiacome from rentand other sources tothe total family Income. Environmental sanitation Form ID: 10. | Type ofhouse T. Rutcha 2. Pucca 3._Semi-pucca 11, | No.ofliving rooms 15. | Kitchen location 12. | Overcrowding E eee 13. | Ventilation ; fordlguat - 1. Adequate 14, | Lighting 2. Inadequate i 2 Separate room Within a room used far other purpose Outside the house 16, | Kitehen type Smokeless Smoky 17. | Bathroom Present within house Present outside house Absent 18. | Sanitary latrine Presentand using Present but not using Absent 19. | Drainage 20. | Source ofdrinking water Proper Improper Hand pump within house Public hand pump Municipal pipe in house Public tap Well within house Public well Pond Mineral/RO water boughtfrom shops in cans 9. Tube well within house 10. Others: SNR ely ele lol alr lee Over crowding criteria Rooms | Persons =| safen]es|ns! Te ‘Maternal health [fill only for married wor men in 15-45 years age gt nap wha have been pregnant in theast ive years) Form ID: ee Se ee, en ee Se ress] ite ent | ee, rau | (inchusing | years tablets) fare T 1. Yes Yes T. Alive 1 Ale on me 5 ; tI CO Currently pregnant women (fill only if there is acurrently pregnant women in the house) a ra | ae vane remmaer oat] | 7m ee ee ive Form ID: practices (ill only for chilrenbelow’ years) ‘Age Prelacteal | Type of reast feed Tyne of weaning food (10) | teed | preacestteca [TanaRR ae ine | Whew sapped] sven at start even hoorsater | (mo) completely (m0) bins T Tine | 1- Sagar water P99. Notatall —[ 99: Notatall 99. Notavall —| 99: Nowyet sated ZWot [2 Honey | given siven riven 1. animal nile given]. Animal mak |. <30min zie 4 Holywater |2.a0min-ahr | 1.

    You might also like