Scribd
Upload
80 views3 pages

HOUSE HOLD PERFORMA Final (DR - Syma)

- The document is a household survey proforma used to collect demographic and health-related information from families. - It collects data on family members' names, ages, education levels, occupations, income, vaccination status of children, housing conditions, prevalence of illnesses, and preferences for health facilities. - The purpose is to understand families' socioeconomic backgrounds, health statuses, and healthcare access and utilization patterns.

Uploaded by

sara
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
80 views3 pages

HOUSE HOLD PERFORMA Final (DR - Syma)

- The document is a household survey proforma used to collect demographic and health-related information from families. - It collects data on family members' names, ages, education levels, occupations, income, vaccination status of children, housing conditions, prevalence of illnesses, and preferences for health facilities. - The purpose is to understand families' socioeconomic backgrounds, health statuses, and healthcare access and utilization patterns.

Uploaded by

sara
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 3

RASHID LATIF MEDICAL COLLEGE, LAHORE

Community Oriented Training Program for Undergraduate Students


HOUSEHOLD SURVEY PROFORMA
Name of Surveyor __________________________________ Class ___________________ Roll No.____________
Batch ______________________________Serial No. ____________________ Date _____________________
Name of Interviewee ____________________________________________ Religion _______________________
Locality/Address ______________________________________________________________________________
1.(a).
Age at
Present Occupation Monthly
Name First Education
Age * Income
Marriage
Head of
Family
Husban
d
Wife
In case of second marriage record age at first marriage.

b). OTHER FAMILY MEMBERS (write in chronological order)

Relationship
Occupation Monthly
Name Age Sex With the Head Education
* Income
of the Family

2.
Type of family: Nuclear Extended
Family members: Male_____________ Female ______________ Total_________________
Total No. of children under five years: ________________
Total number of working members:_________________
Total family income/month: Rs. _____________________
Income percapita / month: Rs. _____________________
____________________________________________________________________________________________

* Classify occupation under one of the following groups:


Farmer, Laborer, Businessman, Employee (Govt./Private), House wife, Student, None.
3. Vaccination status of children upto “2” years of age according to the EPI Program (if applicable):

Sr. Name Age Sex BC Polio (OPV) IPV Pentavalent Pneumococca Rota Measle V. Card
No G (DPT+HepB+Hib) l vaccin s available
. vaccine e vaccine
0 I I II I II III I II III I II I II Ye No
I I s
1
2
3
4
5

 If vaccination card is available;note down the dates on card in respective columns.

4. LIVE BIRTH LAST YEAR:


[ ] No [ ] Yes
If yes sex of new born baby: Male _________________ Female ___________________

5. DEATH LAST YEAR:


[ ] No [ ] Yes
If yes age at death ______________________ Sex ____________________________
Cause of death (if known) ____________________________________________________
6. a). HOUSING
Kacha [ ] Pucca [ ] Mixed [ ]
b). No. of living rooms in the house _________________________________________
c). Animal kept Yes[ ] No [ ]
d). Place where kept Within House [ ] Outside House [ ]
e). If yes, type of animals kept:
Domestic Animals [ ] Number [ ]
Pet Animals [ ] Number [ ]
f). Amenities within the house:
TOILETS WATER SUPPLY ELECTRICITY SUI GAS
[ ] Available [ ] No [ ] No [ ] No
[ ] Not Available [ ] Yes [ ] Yes [ ] Yes
If not available
If yes
[ ] Use of Field
[ ] Well
[ ] Public Latrine
[ ] Hand Pump
If available [ ] Electric Pump
[ ] WC/Pit Toilet [ ] Community Supply
Sewer (Water Carriage)
[ ] Own Arrangement
[ ] Community supply
7. Number of family members having following illnesses: (The disease should be diagnosed by
a qualified doctor):
No. Disease No. of Family member affected Sex
1. Diabetes Mellitus
2. Hypertension
3. Coronary Heart Disease
4. Pulmonary Tuberculosis
5. Hepatitis:
 B
 C
 Others (specify) --------------------------
6. Scabies

8. a). Preference for utilization of available health facilities:

QUACK/
PRIVATE PRIVATE HOMEOP SPIRITUAL
GOVERNMENT HAKIM OTHERMED.
HOSPITAL DOCTOR ATH Healer
PRACTITIONER
CHW / BHU/ RHC DHQ/THQ Teaching
LHW MCH Hospital Hospital
center

b). Reasons for not utilizing Government health facility (if available)

[ ] Unsatisfactory care [ ] Insufficient care


[ ] Costly [ ] Distant
[ ] No information of health care facility [ ] UnsatisfactoryStaff behavior
[ ] Any other reason (Specify): ___________________________________________________

You might also like

pFad - Phonifier reborn

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


Alternative Proxies:

Alternative Proxy

pFad Proxy

pFad v3 Proxy

pFad v4 Proxy