NARAYAN SWAMI COLLEGE OF NURSING

DEPARTMENT OF COMMUNITY HEALTH NURSING

FAMILY FOLDER
BASELINE SURVEY FORM FOR COMMUNITY ASSESSMENT

1. Name of the area Rural/Urban ............................................

2. Name of the Health Centre ............................................
3. Name of the Head of the Family ............................................
4. Type of Family: 4:1 Single ...........................4.2 Joint...........................
5. Religion: 5.1 Hindu ...................... (Specify the subcaste)..........................
5.2 Muslim ...................... ” .........................
5.3 Christian ...................... ” .........................
5.4 Any other ...................... ” .........................
6. HOUSING CONDITION:
6.1 Type of house:
1) Pucca 2) Semi Pucca 3) Kutcha
6.2 Rooms:
1) Number 2) Adequate 3) Inadequate
6.3 Occupancy:
1) Tenant 2) Owner 3) Monthly Rent
6.4 Ventilation:
1) Adequate 2) Inadequate 3) No Ventilation
6.5 Lighting:
1) Electricity 2) Gas Lamp 3) Oil Lamp
6.6 Water Supply:
1) Tap/Handpump 2) Well 3) Open Tank
6.7 Kitchen:
1) Separate 2) Corner of the room 3) Veranda
6.8 Drainage:
1) Adequate 2) Inadequate 3) No Drainage
6.9 Vatory
1) Own Latrine 2) Public Latrine 3) Open Air Defecation
 7. FAMILY COMPOSITION:
Sr. Relationship
Name Age Sex Education Occupation Income
No. with Head

7.A TOTAL INCOME OF FAMILY 7.B EDUCATIONAL STATUS NUMBER

a) Below 500 a) Not Literate ...............
b) 500 – 1000 b) Primary Education ...............
c) 1000 – 1500 c) Middle School ...............
d) 1500 – 2000 d) High School ...............
e) 2000 - & above e) PUC & above ...............

8. TRANSPORT & COMMUNICATION MEDIA 8.1 COMMUNICATION

1) Transport 1) Telephone.................
2) Owns Tempo / Tractor............ 2) Television.................
3) Uses B.T.S. / KSRTC............. 3) Radio..................
4) Uses Private Buses................. 4) Newspaper/Magazine...........
5) Train................ 5) Post & Telegraph.................

8.2 LANGUAGE:
1) Mother Tongue.................. 1) Hindi Read/Write
2) Punjabi...................... 2) English Read Write
3) Hindi.................... 3) Punjabi Read/Write
4) Others............... 4) Specify others.....................
9. DIETARY PATTERN:
Food Preparation and Storage
Food Available Foods Used
Traditional Ideal Unhygienic
Rice
Ragi
Jawar
 Wheat
Vegetable
Fish
Meat
Egg
Milk and Products
Pulses
Tubers
Others

10. STATEMENT OF EXPENDITURE OF THE FAMILY:

Sr.
Item Amount Spent (Approx) % of Total Expenditure
No.
1. Food
2. Clothing
3. Housing (Rent)
4. Medicine
5. Children Education
6. Recreation (Movies Etc.)
7. Smoking & or Liquor
8. Debt
9. Savings
10. Others (Specify)

11. Is there any case of fever – (If yes, write name, age, treatment with remarks)
With Rigors?
With Cough?
With Rash?
Sr.
Name Age Disease Treatment Remarks
No.
1.
2.
3.
12. DOES ANYONE HAVE ANY SKIN DISEASE (Eg. Itching, Patch, Rash)?
Sr.
Name Age Disease Treatment Remarks
No.
1.
 2.
3.
13. DOES ANYONE HAVE A COUGH MORE THAN TWO WEEKS?
Sr.
Name Age Disease Treatment Remarks
No.
1.
2.
3.
14. DOES ANYONE HAVE ANY OTHER ILLNESS?
Sr.
Name Age Disease Treatment Remark
No.

15. HAS ANY WOMEN PREGNANT? If yes, write the following remarks.
Specify gravida.
Has she been registered?
Is she getting Iron and Folic acid?
Has she had Tetanus Toxoid?
Sr.
Name 15.1 15.2 15.3 15.4
No.
1.
2.
3.
16. HAVE THERE BEEN ANY (within year) – Vital Statistics.
BIRTH?
Sr.
Date of Birth Sex Parents Name Remarks
No.
1.
2.
3.
DEATHS?
Sr.
Date of Birth Sex Parents Name Remarks
No.
1.
2.
3.
MARRIAGES?
 Name Age Date of Marriage Remark
Bride
Bridegroom
17. ARE THER ANY CHILDREN BELOW FIVE YEARS WHO HAVE NOT RECIEVED
IMMUNISATION (Specify name, age, reason, for not immunises in remarks)
B.C.G. VACCINATION
D.P.T. VACCINATION
POLIOMYELITIS VAC
MEASLE VACCINATION
VIT. A. SOLUTION
Sr. 17.2
Name Age Sex 17.1 17.3 17.4 17.5
No. 1 2 3
1.
2.
3.
4.

Remarks..............................................................................................................................................................
..........
18. IS THERE ANY ELIGIBLE COUPLE: (if so list them on priority)
Sr. II Primary Secondary Early
Name Age Sex I Priority
No. Priority Sterility Sterility Menopause
1.
2.
3.
18.1 Using a contraceptive method? Is yes specify.................
18.2 Intending to undergo 18.2.1 Vasactomy......................................
18.2.2 Tubal Ligation...................................
18.3 Not interested to adopt F.P. Method (State the reason)
19. IS THERE ANY CHILD 0 – 5 YEARS IN FAMILY WHO SHOW SIGNS OF: MALNUTRITION
Kwashiorkor?
Marasmus?
Vit. A. Deficiency?
Anemia?
Rickets?
 Sr.
Name Age 19.1 19.2 19.3 19.4 19.5
No.

Remarks..............................................................................................................................................................
..........

20. Is the sullage water being disposed of hygienically? If yes Tick any one/all
1. Drain 2. Soakpit 3. Kitchen Garden
If no State
Reasons..................................................................................................................................................
21. Is the rubbish being disposed hygientcally? If yes Tick any one.all
1. Composing 2. Burning 3. Burying
22. Is the excreta being disposed hygienically? Yes/No, If no state reason.
State
Remarks.......................................................................................................................................................
23. Are the cattle and poultry house hygienically?
State
Reasons.......................................................................................................................................................
24. Is there is a well or handpump?
24.1 Is it maintained in good order. If no state reasons Yes No
24.2 Where was the well chlorinated? Date? If no state reasons Yes No
25. Whether house kept clean? If no state reasons Yes No
26. When was the house last sprayed? Date? If no state reasons Yes No
27. Is there any breeding place of insects and rodents? Yes No
28. Are there any stray dogs in the vicinity? If yes write approximate number of dogs. Yes No
29. If anyone falls ill where do you get treatment? Yes No
Hospital/Primary Health Centre.
Subcentre Primary Health Unit.
Private Nursing Homes.
Indigenous Doctor/Local Vaidya.
30. Is official health agencies services adequate? Yes No
If No state
reasons......................................................................................................................................................
Note: In an addition to the above students are expected to obtain following information by
observations and other methods.
1. Description of the community location, topography, climate, history etc. Type government, No. of
schools, No. of health care agencies, Balwadi of ICDS centre places of worship (eg. Temple) and
any other relevant information related to health.
2. List the target couple with details on priority basis.
3. Maintain record of “Road to Health Card” for knowing the degree of malnutrition for under 5s
wherever necessary and use Nutritional Assessment Form promptly.
4. Use problem solving approach/construct good nursing care plan by using “PRONE” format taught
you in recent “Community Nursing Process” Lectures.
5. Remarks can be written in separate sheets quoting code no.
(For eg. 13.2 No. sensations found on the patches needs referral and follow up services).

Date of Survey Name & Signature of Student