FAMILY 1
Name of the Village: Nearest Bus stop:
Ward: Nearest school:
Panchayat/Municipality: Nearest Anganwadi centre:
Nearest PHC:
Nearest Tertiary Care Referral Centre:
Area Map:
House map: Cross sectional at window level
I. DEMOGRAPHIC DETAILS:
Name of the head of the family:
Address:
Migrated: Yes/ No
If yes details: Duration: Previous Place: Reason for Migration:
Religion: 1. Hindu 2. Muslim 3. Christian 4. Jain 5. Others
Contact No:
Aadhar card number (HOF):
II. DETAILS OF THE FAMILY:
1. Family type: 1. Nuclear 2. Joint 3. Three generation 4. Others:
2. No. of members in the family:
3. Income (per capita per month):
4. Class (According to updated BG Prasad Scale - Refer Annexure I)
A. Upper class B. Upper middle class C. Middle class
D. Lower middle class E. Lower class
5. Expenditure pattern:
Item Amount spent per Item Amount spent per
month month
Rent Electricity
Food/Groceries Savings
Health care Transport
Education Others
6. Family Composition:
S. Name Relation to Age Gender Marital Status Education Occupation Income Personal Medico-social
No the Head (M/S/W/D) * (per Habit** conditions***
of the month)
family
*M- Married, S- Single, W- Widow, D-Divorced
**1. Tobacco 2. Smoking 3. Alcohol 4. Others 5. None
***Medico social conditions
Physiological conditions: Infants, Pregnancy, Lactation, old age
Medical conditions: Leprosy, TB, cancer, hypertension, diabetics, HIV, COVID-19, etc
Present Treatment of any medical conditions if any:
Socio conditions: Disability, mental retardation, psychiatric conditions, alcoholic, unwed pregnancy, divorce,
infertility etc.
7. Pedigree chart:
8. Vital events in the past 1 year:
Marriage / Divorce Birth Death Adoption
Yes/No Yes/No Yes/No Yes/No
If yes, registered or If yes, registered or If yes, registered or If yes, registered or
not: not: not: not:
III. ENVIRONMENT
EXTERNAL / MACRO ENVIRONMENT:
Accident prone area: Yes / No If Yes How? ------
Vector breeding sites: Present / Absent If yes what? -----
Street light: Present / Absent
Stray animals: Present / Absent If yes what? -----
Other Significant Observations if any:
INTERNAL / MICRO ENVIRONMENT:
Details Type Findings Remarks / Others
House
Ownership Own / Rented
Setback Adequate/ Inadequate/ Nil
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House Pucca / Semi-pucca / Kutcha
Floor 1. Even/ Uneven
2. Mud/cement/ Tiles
3. Infestation of rodents/ visible
cracks & crevices
Roof Thatched/tailed/RCC-sheets
/asbestos sheet/others
Walls Cracks and Crevices: present/
absent
Dampness Present/ absent
Overcrowding Yes / No
1. Number of living rooms:
2. Per capita space in the house
(square feet per person)
3. Social (Sex separation)
Lighting Natural (Adequate/ Inadequate)
Artificial (Adequate/ Inadequate)
Ventilation Adequate/ Inadequate
1. No of windows (with
measurement)
2. No of doors (with
measurement)
3. Total floor space
Cross Present / Absent
Ventilation
Water supply
Water supply Hand Pump / House Tap / Well /
for household Street Tap / Tank/ Others
use
Water Supply Hand Pump / House Tap / Well /
for drinking Street Tap / Tank/ Others
Storage of Pot / Plastic / Steel container,
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water Open /closed
Purification of Boiling / RO filter / None
water
Toilet and bathing area
Toilet Own / Community Toilet / Open
Type of latrine Indian / Western
Connected to A septic tank/ municipal sewerage
system/other
Toilet Continuous water supply/
Maintenance Lighting availability
Hand washing Without soap/ with soap / No
practices handwashing
Bathing area Present/ absent
privacy
Accident Present/ absent
proneness
Drainage Open/ closed
Waste disposal
Solid Waste Open Dumping/ Panchayat
Disposal collection/ Others
Frequency of Daily, weekly
disposal
Segregation of Present/ absent
waste
Waste Lid/No lid
containers
Kitchen
Separate Yes / No
Kitchen
Platform used Yes/ No
for kitchen
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Fuel for Firewood / Gas / Kerosene /
cooking other
Smoke outlet in Present/ Absent
the kitchen
Storage of food Present/absent,
items
if present method of storage for
Raw food :
Cooked food :
Biological environment
Rodent/ vector Yes/ No
infestation If yes, what
Cattle shed Present/ Absent. If present, at
what distance?
Pet Animals Yes / No
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