Form ID:

1

Department of Community Medicine VMCH & RI, Madurai

Family health survey General info 1. House no. / EB no.

2. Street or area name 3. Name of head of the family

4. Education of the head of the family 5. Occupation of the head of the family 6. Total family income Rs. 7. Total no. of family members 8. Type of the family 1. Nuclear 2. Extended 9. Religion of the family 1. Hindu 2. Islam 3. Christianity Family members No. Name Age

(yr) Sex Relation

with head

Marital status

Edu Occu Income Per month

1. 0

2.

3.

4.

5.

6.

7.

Codes: Sex: 1-Male, 2-Female

Relation with head 0-Head 1-Wife 2-Husband 3-Son 4-Daughter 5-Son in law 6-Daughter in law 7-Grand children 8-Other (uncle, aunt, nephew, niece etc.,)

Marital status: 1-Never married 2-Currently married 3-Divorced 4-Widowed 5-Separated

Education: 1-Not yet started school 2-Still studying 3-No formal schooling but can read and write 4-Completed primary school (1-5 std) 5-Completed middle school (6-8 std) 6-Completed secondary school (9-10 std) 7-Completed higher secondary school (11-12 std)

8-Completed diploma 9-Completed college degree

Occupation: (only for persons aged 14 and more) 1-Still studying or student 2-Unemployed (not studying, not working)

3-Retired from work (for persons aged >60 years) 4-Unskilled 5-Semiskilled, 6-Skilled

Income: Ask about the usual income per month

Add income from rent and other sources to the total family income.

Form ID:

2

Environmental sanitation

10. Type of house 1. Kutcha 2. Pucca 3. Semi-pucca

11. No. of living rooms

12. Overcrowding 1. Present 2. Absent

13. Ventilation 1. Adequate 2. Inadequate

14. Lighting 1. Adequate 2. Inadequate

15. Kitchen location

1. Separate room 2. Within a room used for other

purpose 3. Outside the house

16. Kitchen type 1. Smokeless 2. Smoky

17. Bathroom 1. Present within house 2. Present outside house 3. Absent

18. Sanitary latrine 1. Present and using 2. Present but not using 3. Absent

19. Drainage 1. Proper 2. Improper

20. Source of drinking water

1. Hand pump within house 2. Public hand pump 3. Municipal pipe in house 4. Public tap 5. Well within house 6. Public well 7. Pond 8. Mineral/RO water bought from

shops in cans 9. Tube well within house 10. Others:____________________________

Over crowding criteria Rooms Persons 1 2 2 3

3 5 4 7 5 10

Form ID:

3

Maternal health (fill only for married women in 15-45 years age group who have been pregnant in the last five years) Name Age at

marriage No. of pregnancies in last 5 years (including abortions)

No. of children born in last 5 years

Whether TT taken during last pregnancy

Whether IFA taken during last pregnancy (approx.. 100 tablets)

Place of delivery of last pregnancy

Last pregnancy outcome

Present status of last child born alive (fill only if alive in prev. column)

1 1. Yes 2. No

1. Yes 2. No

1. Hosp 2. Home

1. Alive 2. Stillbirth 3. Aborted

1. Alive 2. Dead

2 1. Yes 2. No

1. Yes 2. No

1. Hosp 2. Home

1. Alive 2. Stillbirth 3. Aborted

1. Alive 2. Dead

3 4 5 Currently pregnant women (fill only if there is a currently pregnant women in the house)

Name Which trimester? Registered or

not so far?

No. of

visits TT1 TT2 TT Booster

IFA received so far or not

Choice of delivery place

1 1. First 2. Second 3. Third

1. Yes 2. No

1. Yes 2. No

1. Yes 2. No

1. Yes 2. No

1. Yes 2. No

1. Home 2. Govt. 3. Pvt.

2 3

Form ID:

4

Child feeding practices (fill only for children below 2 years) No. Name Age

(mo) Prelacteal feed

Type of prelacteal feed given

Breast feeding Type of weaning food given at start Initiation time

(hours after birth)

EBF time (mo)

When stopped completely (mo)

1 1. Given 2. Not

given

1. Sugar water 2. Honey 3. Animal milk 4. Holy water 5. ___________

99. Not at all given 1. <30 min 2. 30 min-1hr 3. 1-4hr 4. >4hr

99. Not at all given 1. <6 months 2. >6 months

99. Not at all given 1. <6 months 2. 6 mo-1 yr 3. > 1 year

99. Not yet started 1. animal milk 2. rice 3. dal 4. vegetable 5. kichdi 6. cerelac, nestum, lactogen, milk powder 7. others ____________________

2

3

Immunization (fill only for children aged 12 to 24 months at present)

No. Name Whether immunization card present

BCG, OPV 0 dose

OPV, Pentavalent Measles

Reasons: If any vaccine is not given 1 2 3

1 1. Yes 2. No

1. Yes 2. No

1. Yes 2. No

1. Yes 2. No

1. Yes 2. No

1. Yes 2. No

2

Form ID:

5

Health care utilization

No. When some one in your family falls sick, where do you go for treatment? (Write the most common option)

1. We don’t go anywhere, prefer home remedy 2. Local healer 3. Govt. hospital 4. Pvt. qualified doctor

1 Reasons for preferring this option (only for options 2,3,4)

1. Known to us 2. Comfortable 3. Cheap 4. Recommended by friends or relatives 5. Others _______________

Diabetes and Hypertension

No. Name What disease? Whether currently taking treatment?

What type of treatment?

Regularity of treatment

1 1. HTN 2. Diabetes 3. Both

1.Yes 2. No

1. Allopathic 2. Alternative medicine 3. Both

1. Regular 2. Irregular

2 3