Diviseema Development Society, Nagayalaka Socioeconomic and Health Survey
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- Title
- Diviseema Development Society, Nagayalaka Socioeconomic and Health Survey
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Diviseema Development Society, NAGAYALAKA
Socio Economic And Haealth Survey.
)
PROFORMA 1
SI. No.
- \\ .
1
2. Street
1, Name of village / urban areas t
3. House No.
4. Name of the head of the family :
5. Type of family :
Single t
5. fa) Family members in the house at
present :
SI.
No.
Name
Sex
Age
Completd
Joint !
Marital status married/
unmarried widowed / divorced
Relationship
to (I)
1. Head of Household
2.
3.
4.
5.
6.
7'8
9.
10.
6. Educational and occupational status
Name of
SI. members
above 5 years
No
primary
Occupation
Education
Hr
Eduction.
Highschool teachnical Non feachnical Agric Fact- Cle- Exe Other
culture ory ricul cutive type
7. Annual Incom
SI.
No.
Name of earning
member
Fixed property
Worth Rs.
Agriculture
source
Emplopment
Others
(specify)
I
I
r
Total Income
8. What is the expenditure ?
Annually on clothing
Occupational requirements
Festivals, weddings, medical aid
Taxes
*—
9. Does the family have any of the following modern conveniences? Bycycle / Car / Scooter-/ Mat
orcycle / Radio / Electrical goods.
10. Diet
a) Vegetarian - non vegetarian
b) No. of meals >er day
c) What is the items of diet consumed
Yesterday
This morning
This afternoon
11. Habits (if yes, who ?)
) No(
) (b) Drinking Yes (
fa) Smoking Yes (
) No (
) No (
)
No (
) (d) Types of recreation Yes f
) (c) Chewing pan Yes (
)
12. Any death in the family during the last 5 Years
SI.
Name
No.
Age at
death
Relation to the
bead of family
Sex
Cause of
death
Live
bir I still birth
13. Any birth in the family during the last 5 Years
SI,
No.
Name
Date of
birth
Prsent
age
Sex
Y ~
3
14
Any major illness among family members during the last 5 years
SL.
No.
Name
Nature of ilines s
taken & Where
Treatment
15. Anyone now having illness, defect or disability in the family
Nature of illness
Name
SI. No.
16. (a) Knowledge about family planning
Yes (
(b) Are they practising family planning ? Yes (
(c) Have they peaciised previously ?
Yes (
Treatment
) No(
) No (
) No (
Taken & Where
)
)
).
if Yes, Indicate method t
17. Immunization status (denot dates)
SL
No.
18. No.
Name
Age
Sei
Small poA- __R r r
Prim. Revac **
Males
of deaths during Cyclone
19. Age jrop of the date
Polio
Othrs
DPT
I 2 3 I 2 3 (Specify)
Female
0- 5
5-15
15-26
26-50
50 & above
20. Aid Receiveb / Covt f Other Voluntary Health Organisations
21. What Rehabilitation mesures do you expect from the Govt / Loca Agencies / Voluntary Organis
ation.
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RF_DM-2_ANP-10_SUDHA.pdf
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