ANNAPOORANA MEDICAL COLLEGE NAME: DEPARTMENT OF COMMUNITY MEDICINE Roll.No

COMMUNITY SURVEY - PROFORMA House No Household No Name of the Informant

S.No Name Age Sex Relationship to head

Marital status

Literacy Lit/Illiterate

Education P/M/S/HS/T/C/Prof

Occupation Income

1

2

3

4

5

6

7

8

NOTE : MARITAL STATUS: S-Single, M-Married, W-Widow/widower, Sep-Separated, D-Divorcee EDUCATION : P-Primary, M-Middle, S- Secondary HS-Higher Secondary, T-Technical Education (Dip.Certificate Courses) Prof – Professional courses. Column number 7 not applicable for those who have had/undergoing formal education Mark Reasons for drop outs: 1. To look after siblings. 2. Economic reasons 3. Loss of parent/s 4. Distance of the school 5. Not interested in study 6. Others (Specify)

2 NAME:

FERTILITY Roll No:

Age Group of mothers No. of mothers Number of Children

born in the past one year

Number of Children ever born

15 - 19

20 –24

25 –29

30 –34

35 –39

40 –44

45 - 49

VITAL STATISTICS (For the past 1 year)

BIRTH DEATH

Name Age Sex Present status Name Age Sex Cause of

death

3ENVIRONMENT NAME ROLL NO

Type of House

Source of Drinking Water

Distance of source

Sanitary Latrine

Hut

Hand pump Present

Semi pucca

Overhead tank Absent

Pucca Well/pond If toilet present in the house : Using/Not using If not using : 1. Problem in water supply

1. Not used to

2. Presence of toilet in the house itself makes foul smell and dirty 4. Others Over Crowding No. of persons in the family : No. of Rooms : No. of persons per room : Over crowding : present / absent

41. MATERNAL HISTORY (for all eligible couples – during last five years) NAME:

Roll.No.

Antenatal care Delivery Outcome Present status Name of EC Age at

marriage Number of

pregnancies in the last 5

years

Regn. TT IFA At home Hospital Live /dead Live /dead

3. PRESENT HISTORY

Immunization IFA

Name Trimester Registered Yes/No

No, of visits by Heath worker/herself

TT - 1 TT -2 Recd. Not Rd. Choice of place of delivery

5

BREAST FEEDING: CHILDREN (up to 2 years) NAME Roll.No.

Name of the child

Place of delivery

Prelacteal

feeding

Breast feeding Weaning Time of initiation of breast feeding

How long exclusively

given

When stopped completely

Time of initiation

Nature of food started

IMMUNIZATION (children between 1 to 2 years.)

Name of child

BCG

OPV DPT Measles 0 dose I II III I II III

CHILD CARE LESS THAN 5 YEARS

1. In case of sickness of child where do you take the baby? GH/PHC/SC/P/private/traditional healers

2. Do you continue regular feeding during bouts of sickness? (Diarrhoea/ARI/Fever) Yes/No

3. Do you weigh your baby regularly? Yes/No If yes, how often? Where?

6MORBIDITY NAME: ROLLNO Point Prevalence 1. Is anybody sick in the family? Yes/No. 1 a) If Yes Name Age Sex Type of Sickness

2. Whether he/she attending to routine work? Yes/No

Period Prevalence

1. Anybody was sick in your family in the past one month? 1a) If Yes Name Age Sex Type of Sicknesss

2. Was he/she attended to routine work during illness? Yes/No

HEALTH CARE UTILISATION 1. When somebody falls sick, where do you go for treatment?

1. GH/PHC/SC 2. Private 3. Traditional healers

2. Reasons for the preference:

3. Distance travelled: