Proforma for village household survey

1. 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. 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

3. 3
ENVIRONMENT 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

4. 4
1. 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. 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?

6. 6
MORBIDITY 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: