Village Schedule

Name of Village: Nearest Post Office:

Total Households: Nearest Bus Stop:

Population: Nearest Railway Station:

• Male: Approach to Village:

• Female: Transport Facilities:

• Children:

Nearest PHC:

Nearest Wellness Centre/Dispensary:

Nearest Maternity Home:

Nearest Tertiary Care Referral Centre :

Community Institutions No. Name

Co-operatives

Library

Youth Association

Women’s Association

Schools

Anganwadi

Religious/Charitable Institutions

Other

Medical Practitioners
• Allopathic
• AYUSH
• Others
Sources of Water: Climate:

Type of Drinking Water Supply: Average Rainfall:

Street Lighting: Predominant Religion:

Major Agricultural Products: Predominant Castes:

Cash Commodities: Fairs & Festivals:

Industrial products: Endemic Diseases:

Cottage & Small Industry:

Name of Sarpanch

Name of CHO

Name of ANM

Name of ASHA

Name of Anganwadi Sevika

Village Map
FAMILY
DETAILS
 Family 1
1. Demographic Information

Unique ID
Name of the head of
Family
Complete Address

Contact no.
Family type: 1. Nuclear 2. Joint 3. Three Generation
Other _________________________
No. of Family Members
Total ______________ Males ______________
Females _______________________
Religion
1. Hindu 2. Muslim 3.Jain 4.Buddhist
5.Christian 6.Sikh
Other ________________________________
Caste Category 1. Open 2.OBC 3.SC 4. ST 5.VJNT 6. SBC
Other ________________________________
Income
(per capita per month)

Class (According to
Updated BG Prasad
Scale)
2. Family Details
No. Name of family member Age Sex Education Occupation Marital Relation Significant
Status to theHead History/
Remarks
3. Diet & Nutrition
Type of Diet: Veg / Mixed Frequency of eating non-veg
per week

Time Particulars Amount

Breakfast

Lunch

Evening Snack

Dinner

Average Monthly Expenditure on Food

Expected Calories: __________________ Deficit/ Excess: __________________

Expected Proteins: __________________ Deficit/Excess: __________________

Fruit intake:

Hand washing:

Is any Food item not eaten?

Is Supplementary nutrition given to children & Pregnant or lactating women?

Method of Cooking

Rice

Roti

Dal

Vegetables
4. Environment
House
• Type of House: 1. Paccka 2. Semi paccka 3. Kachha
• Rooms: Locality/Neighborhood:
• Overcrowding: Present/ Absent
• Owned/ Rented
• Residing Since
• Outset: Open/Closed
• Lighting: Natural (Adequate/Inadequate), Artificial(Adequate/Inadequate)
• Ventilation: Adequate/ Inadequate
Kitchen
• Separate Kitchen: Y/N
• Cooking Fuel:
• Cooking Practices:
• Food Storage:
• Modern Amenities:
Water
• Source: Housing Plan
• Water Supply:
• Purification:
• Waste Disposal:
• Storage :
Sanitation
• Latrine:
• Type:
• Location:
• Privacy:
• Water Availability:
• Cleanliness:
• Solid Waste Disposal:
• Sewage/Sullage/Refuse/Garbage:
Animals
• Animal(s) Reared:
• Cattle Shed:
• Rodents:
• Vector Breeding Sites:
5. Social Habits and Customs
• Social Religious Customs

• Addictions

• Do women work are they educated? Is there Unemployment in Family?

• Have there been instances of Domestic Violence?

• Is there any quarrel with neighbors?

• Outlook towards Family Planning

• Knowledge Attitude and Practices Regarding Common Diseases

6. Economic Status
• Total Income per month: • Adhar Card
• Total Expenditure per month: • Ration Card
• Savings: o White
• Benefit of Government o Yellow
Programmes/Schemes o Orange
• PAN Card
• Insurance

Income Expenditure
1. Rent
2. Food
3. Clothing
4. Education
Entertainment
Fuel/Travel
EMI
Addictions
Medicines & Health
Other
Assets Liabilities

7. Vital Events (in past year)

Births Deaths
• Sex of Child • Cause
• Detailed Birth History • Age
• Place of Delivery • Sex

Marriage: Migration:
Age at Marriage • To
Arranged/Love • From
Interfaith/ Inter-caste • Reason
8. Preventive Check-up (Examination of Family Members)
1) ANC/PNC

Name Age:
Visit Date Age at Marriage
Individual No. Age of Menarche:
Obstetric Score G P L A

LMP Past History:

EDD
ANC visits

Personal History:
Counselling

Family Planning?
Significant
Medical History
General
Examination
Systemic
Examination

Significant Delivery Details:

findings on
Investigation
Significant Post
Natal History
Advice Given
2) Children

Name
Birth History
Immunization Status
Significant Medical History
(eg. ARI, Diarrhoea, Sepsis
,Anaemia, 4 Ds , VPD,
SAM/MAM, Other)
Anaemia, and other Deficiencies,
Growth abnormality, Substance
abuse etc
Treatment History

Remarks

Name
Birth History
Immunization Status
Significant Medical History
(eg. ARI, Diarrhoea, Sepsis
,Anaemia, 4 Ds , VPD,
SAM/MAM, Other )
Anaemia, and other Deficiencies,
Growth abnormality, Substance
abuse etc
Treatment History

Remarks

Prepare a Pedigree Chart

3) Family planning, Contraceptive services and Other Reproductive Health Care services:

Visit Name Method of family Health institute Any difficulty Remark

Date planning or which provided while using
contraceptive this service family planning
used or contraceptive
methods

4) Other Health Problems (CDs, NCDs. Geriatric Health, Mental Health)

Visit Name Signs & Treatment Advice

Symptoms/Diagnosis
 Visit Summary
Topic:- Date:-
Individual activity:

Group activity:

Gaps Identified:

Health Messages given:

 Family Follow-up

Date:

Date:

Date:

Date:

Date:

Date:

Signature of Student: Signature of Mentor: