Family folder format

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COMMUNITY HEALTH NURSING



(NO. _____)












NAME OF STUDENTS :- _________________________________

CLASS :-__________________________________

DATE FROM :-________________ TO ______________

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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

1.Type of House: Completed Independent Tileld Sheeted
Hut Owned Rented

2. Rooms : Number - Adequate Inadequate

3. Kitchen : Separate Attached to room.

4. Fuel Used : Gas Kerosene Fire Wood Electricity

5. Ventilation : Adequate Inadequate

6. Bath Room : Separate Common

7. Lighting : Electricity Oil Lamp

8. Drainage : Open Close

9. Water Supply : Tap/Hand Pump Well Chlorined. - Yes/No Open Tank Chlorinated

10 Toilet : Own Public Open field

11 Disposal of Waste:Composing Burning Buying

12 Cattle Shed : Separate Within the House

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3. FAMILY COMPOSITION

S
N
Name Relationship
With Head
of the Family
Age Sex Education Occupation Health
Status
Immun
ization
Status
1
2
3
4
5
6


4. TRASPORT AND COMMUNICATION FACILITIES B. Communication Media

A. Transport Yes No
Own Yes/No Telephone

Tractor Tempo Wheeler Television

Bus City Bus RSRTC Private Radio

Autos Taxies Train Newspaper/Magazines
Post & Telegraph

5. LANGUAGES KNOWN

Marwadi Mewadi Gujrati
English Hindi Any Other

6. A)NUTRITIONAL PATTERN

Vegetarian Non Vegetarian
Staple Food : Rice Wheat Ragi Mixed
Vegetables : Grown Purchased Quantity used per day: ……kg
Milk : Quantity used per day ………litres
Non Vegetarian Dish: Specify…………………. How often ……………

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B) NUTRITIONAL STATUS OF FAMILY MEMBERS

Name of the Member Nourished/Under Nourished Malnutrition









7. RECORD OF ILLNESS

Name of the Member Age Illness Duration Main Investigation Treatment
Characteristics done









7. PREGNANT WOMAN


Name Age Gravida No. of Children Whether Registered in Receiving Iron
& Para Living Hospital/Nursing Home and Folio Acid







9. ELIGIBLE COUPLES

Name Age Family Planning Method Not interested willing to use
Adopted in Family Planning Family 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

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NURSING CARE PLAN



Assessment Nursing Diagnosis Objective/ Goals Nursing Interventions Evaluation Outcome

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Assessment Nursing Diagnosis Objective/ Goals Nursing Interventions Evaluation Outcome

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Vital Sign GRAPHIC SHEET
* Mouth
* Rectal
Month……………………….


Name, Age, Sex, Status Religion Hospital No.
Occupation, Income Ward, unit, Bed No.
B.P.
7a.m. to 7p.m.
(Total in m.l.)
Intake
7p.m. to 7a.m.
(Total in m.l.)

7a.m. to 7p.m.
(Total in m.l.)
Urine
7p.m. to 7a.m.
(Total in m.l.)
Stools No. of Times
Aspiration/Drainage
(24 Hrs. Total in m.l.)
Sputum
Weight
Bath


Date:
No. of Days
Days Post-op
Time
Pulse
Temp
C F



210 41.1 106
200 40.6 105
190 40.8 104
180 39.4 103
170 38.9 102
160 38.3 101
150 37.8 100
140 37.2 99
130 36.7 98
120 36.1 97
110 35.6 96
100 35 95
90 Resp-060
80 50
70 40
60 30
50 20
40 10

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NURSE’S NOTES


Date Time Nursing Intervention Signature