Community Health
Nursing
Family Folder
No. ( )
Student Name : ……………………………………….
Class : ………………………………………..
Date From :…………… To :…………………….
FAMILY PROFILE DATA
Primary Health Centre: ________________________________
Sub Centre : ________________________________________
Name of the Village: _________________________________
1. IDENTIFICATION INFORMATION
Head of family:__________________________________________
Name: _________________________________________________
Occupation:_____________________________________________
Address: _______________________________________________
___________________________________________________________
Type of family: Nuclear ( ) Joint ( )
Religion: Hindu ( ) Muslim ( )
Christian ( ) Any other ( )
2. HOUSING CONDITION
Type of House: Completed ( ) Independent ( ) Tile Sheeted ( )
Hut ( ) Owned ( ) Rented ( )
Rooms : Number ( ) Adequate ( ) Inadequate ( )
Kitchen : Separate ( ) Attached to room ( )
Fuel Used : Gas ( )Kerosene ( )Fire Wood ( )Electricity ( )
Ventilation : Adequate ( ) Inadequate ( )
Bath Room : Separate ( ) Common ( )
Lighting : Electricity ( ) Oil Lamp ( )
Drainage : Open( ) Close ( )
Water Supply : Tap/Hand Pump ( ) Well Chlorined. - Yes/No Open
Tank Chlorinated
Toilet : Own( ) Public ( ) Open field ( )
Disposal of Waste: Composing ( ) Burning ( ) Buying ( )
Cattle Shed : Separate ( ) Within the House( )
3. FAMILY COMPOSITION
Relationship
S.N. With Head Health Immunization
Name Age Sex Education Occupation
of the Family status Status
1
2
3
4
5
6
7
8
9
4. TRANSPORT AND COMMUNICATION FACILITIES
A. Transport : Yes /No
Own Yes/No ( )
Tractor ( ) Tempo ( ) Wheeler ( ) Bus ( ) City Bus ( )
RSRTC ( ) Private ( ) Autos ( ) Taxies( ) Train ( )
B. Communication Media : Yes /No
Telephone : Yes /No
Television : Yes /No
Radio : Yes /No
Newspaper/Magazines : Yes /No
Post & Telegraph : Yes /No
5. LANGUAGES KNOWN
Hindi ( ) Punjabi ( ) Gujrati ( ) English ( ) Marwadi ( )
Any Other ( )
6. NUTRITIONAL PATTERN
A. PATTERN: Vegetarian ( ) Non Vegetarian ( )
Staple Food: Rice ( ) Wheat ( ) Ragi ( ) Mixed ( )
Vegetables: Grown ( ) Purchased ( ) Quantity used per day:
……kg
Milk: Quantity used per day ………liters
Non Vegetarian Dish: Specify…………………. How often
……………
B. NUTRITIONAL STATUS OF FAMILY MEMBERS
Name of the Member Nourished/Under Malnutrition
Nourished
7. RECORD OF ILLNESS
Name of Age illness Duration Main Investigation Treatment
the characteristics done
Member
8. PREGNANT WOMAN
Name Age Gravid & No. of Whether Hospital/Nursing
Para children Registered in Home
living Receiving Iron
and Folio Acid
9. ELIGIBLE COUPLES
Name Age Family Planning Method Not interested Willing to use
adopted in Family Family Planning
Planning method
10. IN CASE OF SICKNESS, WHERE DO YOU GO FOR
TREATMENT?
Name/Primary Health Centre ( ) Private Nursing Home ( )
Sub Centre ( ) Indigenous Doctor/Dai ( )
Nursing care plan
Assessment Nursing diagnosis Objectives/goal Nursing Evaluation
intervention outcome
Nursing care plan
Assessment Nursing diagnosis Objectives/goal Nursing Evaluation
intervention outcome
Nurses notes
Date Time Nursing intervention Signature
