RAJSHREE NURSING INSTITUTE, BAREILLY (U.P.
)
FAMILY FOLDER
HEAD OF THE FAMILY :................................................................................................
FATHER’S NAME :................................................................................................
ADDRESS :................................................................................................
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DATE OF VISITING FAMILY :................................................................................................
SUPERVISED TO SUBMITTED TO:
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SUBMITTED BY............................................................
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SUBMITTED ON
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FAMILY ASSESSMENT FORM
FAMILY FOLDER NO...................................................................
1) NAME OF THE HEAD OF THE FAMILY.................................
2) AGE SEX
3) HOUSE NO................................
4) NAME OF THE FAMILY MEMBERS THEIR RELATIONSHIP WITH HEAD OF THE FAMILY
S.No Name Age Sex Relationship Education Occupation Income Remark
With HOF
5) FAMILY CHARACTERSTICS LOW/HIGH
6) TYPE OF FAMILY
i)Joint ii) Nuclear
7) RELIGION ...................................................................
8) EDUCATION STATUS ..................................................................
a) Not Literate ..................................................................
b) Primary Education .................................................................
c) Middle school ..................................................................
d) High school / Inter [10+2]..............................................................
e) Graduate / Post graduate..............................................................
10) LANGUAGE KNOWN
i) Mother Tongue Read/Write/Speak
ii) Regional Read/Write/Speak
iii) Hindi Read/Write/Speak
iv) English Read/Write/Speak
v) Other Read/Write/Speak
11) TOTAL MONTHLY INCOME OF FAMILY .......................................................
12) MONTHLY EXPENDITURE .......................................................
13) OCCUPATION
1) Husband .......................................................
2) Wife .......................................................
14) No.& VARITY OF ANIMALS ......................................................
15) OTHER PROPERTY BICYCLE/T.V./RADIO/STEREO
16) SEWING MACHINE .......................................................
17) LAND OWNED YES / NO
18) AREA OF LIVING RURAL / URBAN
IF YES
1. Cultivated ......................................................
2. Non-Cultivated .......................................................
19) TYPES OF HOUSE CHARACTERSTICS
i) Kuccha/Semi Pucca/Pucca .......................................................
ii) Own Or Rented .......................................................
iii) No.Of Rooms
(Number/Adequate/Inaequate) .......................................................
20) HYGENIC OR UNHYGENIC ........................................................
21) SOURCE OF LIGHT Electricity/Candle/Kerosene Lamp
22) VENTILATION Adequate/Inadequate/Absent
23) WATER RESOURCES Tap/Hand Pump/Well/Canal
24) DRAINAGE Open/Close/No drainage
25) KITCHEN CONDITION Hygienic/Unhygienic
26) KITCHEN Separate/In varandah/In living room
27) LAVATORY Open latrine/Public latrine/defecat.
28) FUEL USED Kerocene/Lakadi/Coal/Gas
29) METHOD OF REFUSE DISPOSAL Burning/Dumping/Composing
30) METHOD OF EXCRETE DIPOSAL Open Field/Toilet
31) SHADES OF DOMESTIC ANIMALS Absent/Present
32) GENERAL ENVIRONMENT CONDITION Safe/Unsafe
33) TREES Yes/No
34) DURATION OF RESIDENCE AT THE
PRESEN ADDRESS ..........................................................
35) TRANSPORT & COMMUNICATION MEDIA:-
1. Own Tempo/Tractor i) Telephone
2. Govt. Bus /City Bus ii) T.V.
3. Pvt. Bus iii) Radio
4. Train/Tram iv) News Paper/Magazine
v) Post & Telegraph
36) ECONOMIC CONDITION:-
Income-Daily/Monthly/Yearly/Amount .............................................................
Total expenditure for
food,fuel,housing,clothing.............................................................
Housing...................Clothing............................Education................................................
Sickness............................Toilet...........................................
Family economic Security Insurance................................................................................
Postal...................Saving...................................Others....................................................
Debt, due to Sickness........................................Marriage................................................
Poor Economic Condition................................Others......................................................
38) CULTURAL BACKGROUND
FOOD HABITS Vegetarian/Non Vegetarian/Both
Food Available Food Uses Food preparation & Storage
Rice
Raji
Jawar
Wheat
Vegetable
Fish
Meat
Egg
Milk
Milk Product
Pulses
Other
38) ATTITUDES Spiritual/Fatalistic / Demonistics
39) INTRA FAMILIAL RELATIONSHIP Good/Fair/Tension/Conflict
CRISIS ...........................................................
40) CAUSES OF PRESENT ILLNESS AS
GIVEN BY THE FAMILY ..........................................................
41) EFFECT OF ILLNESS ON OTHER
MEMBERS OF THE FAMILY ..........................................................
42) SOCIAL & VOLUNTARY AGENCIES
WORKING IN THE AREA ..........................................................
43) ANY PERSON DEATH IN THE FAMILY YES/NO
(WITH IN ONE YEAR)
NAME......................................AGE..................................SEX...........................................
44) Is there any case of fever-(If Yes, Give Details)
(i)With Rigors (ii) With Cough (iii) With Rash
S.No NAME AGE DISEASES TREATMENT REMARK
.
1
45) Does anyone have any skin diseases (If Yes, Give i.e.Itching,Patch,Rash)
NAME AGE SEX DISEASES TREATMENT REMARK
ITCHIN
G
PATCH
RASH
46) Does anyone have a Cough for more than Two weeks (If Yes, Give Details)
S.No NAME AGE SEX DISEASE TREATMENT REMARK
.
47) Does anyone have any other illness (If Yes, Give Details)
S.No NAME AGE SEX DISEASE TREATMENT REMARK
.
48) Is any women pregnant (If Yes,Give the following Remarks)
i) Specify Gravid ................................................................
ii) Has she been registered .................................................................
iii) Is she getting I.F.A. ..................................................................
iv) Has she had T.Toxoid .................................................................
49) Have there been any (If Yes , Give Details)
A) BIRTH
S.No NAME SEX PARENT & NAME REMARK
.
B) DEATH
S.No DATE OF DEATH SEX PARENT & NAME REMARK
.
C) MARRIGES
NAME AGE DATE OF REMARK
MARRIGE
BRIDE
BRIDE-
GROOM
50) Are there any children below five year who not received Immunization?
(If Yes , Give the following details)
NAME AGE SEX B.C.G. OPV/DPT MEASLES VIT.A
1 2 3
51) Is there any eligible couple (If Yes, List them on priority)
S.No NAME AGE SEX PRIORITY P. S. E.MENOPAUSE
. STERLITY STERLITY
52) Using a Contraception method ? If yes, Specify.
i) Oral Pill ...........................ii) Nirodh............................iii) Any other............................
53) Not interested to adopt F.P. method (State Reason)
54) Is there any child of 0.5 years in family? If yes, show sign of Malnutrition.
55) Is there any child in family who is physically handicapped/ mentally disturbed?
56) Is the silage water being disposed off hygienically? YES/NO (If Yes ,Tick on the
following box)
i) Drain ii) Soak pit iii) Kitchen Garden
57) Is the excreta being disposed off hygienically? YES/NO (If No state Reason)
58) Are the cattle and poultry house hygienically? (a)Separate (b) With in house?
59) Is there a Well or Hand pump?
a) Is maintain in good order? YES/NO(If no state reason)
b) When was the well chlorinated? Mention the Date? (If no state reason)
60) Is there any breeding place of insects & rodent ? YES/NO
61) Are there any street dog in the vicinity? YES/NO
62) If anyone falls ill where do get treatment?
Hospital/PHC/SC/CHC/Pvt.Nsg.Home/Local Vaidhya/Pvt.Practitioner/Family
doctor/Rajshree IMS.
63) Are official health agencies services adequate YES/NO
Date of Survey
Signature of Student
