VISITS IN FIRST

PROFESSIONAL
YEAR
[9]
 VISIT 1, 2 AND 3

INFORMATION ABOUT THE VILLAGE

1. Name of the village:

2. Panchayat:

3. Mandal: District: State:

4. Total Population of Village:

5. Total number of families:

6. Communications:

a) Bus/Rail services:

b) Post, telegraph, telephone services

7. Places of Worship: Temple / church/ Masjid / other

8. Public Latrines:

9. Educational Institutions: .

(a) Primary

(b) Middle,

(c) Higher Secondary, and above

10. Industries:

11. Major Crops:

12. Animal husbandry:

13. Water sources: Disinfection: yes / No If yes, how frequently:

14. Refuse disposal:

15. Drainage facility: yes/no open/closed: -

16. Public lavatories:

17. Disposal of liquid wastes:

18. Recreational facilities:

19. Availability of shops : Yes /No If yes, what kind of shops:

20. Health infrastructure:

(a) Health Centre:

(b) ICDS Centre/ ANGANWADI:

(c) Multipurpose Health Workers: - Name: Address:

Experience :

(d) ANM: Name: Address:

Experience:

(e) Anganwadi Worker: Name: Address:

Experience:

(f) ASHA worker: Name: Address:

Experience:
 (g) Private practitioners:

(i) Allopathic: -

(ii) AYUSH: -

21. Village Health Committee: Mukhiya:

22. Voluntary agencies like Mahila Mandals, Youth Organizations etc.

23. Name of the village leaders:

24. Endemic diseases: - (Malaria, Flu, Typhoid, TB, Filaria, etc)

OTHER INFORMATION: -
SKETCH MAP OF THE VILLAGE
 FAMILY HEALTH SURVEY- 1

HOUSE MAP (Family No. ……….)

Location of the House:

W E

S
Cross section of House

W E

S
OTHER AND EXTRA INFORMATION
 VISIT 4 & 5
FAMILY HEALTH STUDY-1
Date of visit by Medical Student:

Address:

Name of the Head of the Family:

Family No.:

Religion:

Caste:

Relationship to

Addictions (if
immunization
Occupation

the Head of
Education
Age/ Sex

Income

on(<5yr)
SI.No.

Name

family

any)
Health
status
Type of Family: Nuclear/Joint/Three Generation

Total family members:

Social Class according to BG Prasad classification/Kuppuswamy:

Per capita monthly income = Monthly income of all family members :

SES class:-

Sources of income: -Laborer/Land owner/teacher

Children Education

Child-1

Name of the school: -

Annual progress of education of children: -

School grade: -

Medium of learning:-

Child-2

Name of the school: -

Annual progress of education of children: -

School grade: -

Medium of learning: -
 Vital events ( one calendar year) : Birth(s):

: Death(s)

: Marriage(s)

Services available : Allopathic / Homeopathy / Ayurvedic /others

Services utilized (Mention the agency of service)

a. Antenatal

b. Child Health including immunization

c. Family planning

d. Medical care

e. Other special services, if any

Family Planning information ( if target couples)

a. Target couple number ( if more than one in the same family)

b. Name of the husband Age :

c. Name of the wife Age :

d. Name of living children with ages and Sex:

e. Age of the last living child :

f. Family planning practice: Yes / No

g. Method ( if yes)

h. If no, attitude towards family planning : favorable / neutral / unfavorable

i. Advice given:

j. Follow up:
OTHER AND EXTRA INFORMATION
 VISIT 6 & 7
FAMILY DIET HISTORY :( by 24-hour recall method)

Sufficiency
Family (excess, No. calories Protein
Required consuming Fat intake
member deficient, excess/deficient intake
suffice)
Fruits intake: -

Salt intake: -

Fibre food intake (by any form):-

Food fads and fallacies:-

Exclusive breast feeding (in PNC ):-

Any other specific dietary habits: -

Notes:

Balanced Diet: A diet may be defined as the kinds of food on which a person or group lives.

A balanced diet is one which provides all the nutrients in required amounts and proper

proportions. A balanced diet should provide around 50-60% of total calories from

carbohydrates, preferably from complex carbohydrates, about 10-15% from proteins and 20-

30% from both visible and invisible fat. In addition, a balanced diet should provide other non-

nutrients such as dietary fibre, antioxidants and phytochemicals which bestow positive health

benefits. Antioxidants such as vitamins C and E, beta-carotene, riboflavin and selenium protect

the human body from free radical damage. Spices like turmeric, ginger, garlic, cumin and

cloves are rich in antioxidants.

KAP OF BALANCED DIET: -

KAP OF EXCLUSIVE BREAST FEEDING: -

OTHER AND EXTRA INFORMATION
 VISIT 8 & 9

HOUSING AND ENVIRONMENT

1. House: Own House / rented house

2. Type: Pucca house / Kaccha House

3. Location of the house: elevated / Low laying

4. Distance from a) P.H.C./ Hospital b)Primary School/ High school / college c)bus

Complex / Railway station d) Recreation facilities such a parks / Cinema / Others.

5. Is the house secluded / promotes social relation?

6. Set back allowed around the house for improved light and ventilation?

Front Rear Both sides

7. Built up area of the house? >1/3 site 2/3 site / whole

8. No. of living rooms in the house. Floor Area:

9. No. of residents in each living room?

10. Overcrowding: Present / Absent

11. Type of the floor: Easily Washable / Impermeable / Damp proof / Others

12. Wall construction: Cement / Brick / Mud / Others

13. Light: Sufficient / Insufficient.

14. No. of windows: windows area > 1/5 of floor area Yes/No.