“A STUDY ON HEALTH STATUS AND HEALTH PRACTICES OF SUGALI COMMUNITY IN KHAMMAM MANDAL”

FAMILY SCHEDULE
Village Family No.

Name of Head of family Religion

Type of family: Nuclear / Joint / Three generation

Relationship General
Age Marital Status Consanguinous Education
Sl. No. Name Sex marriage with Head of Occupation Income Health Status Remarks
(yrs) S/M/W/D/Se
Y/N family W/AS / CS /D

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No of deaths in the family in last one year If any, State the age at death and cause of death:
No. of maternal deaths due to puerperal causes
No. of infant deaths - M - F - Total
No. of births – M - F - Total

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“A STUDY ON HEALTH STATUS AND HEALTH PRACTICES OF SUGALI COMMUNITY IN KHAMMAM
MANDAL”

FORMAT OF HOUSING AND SANITATION

1 Family Number

2 Type of Housing Kutcha / Pucca / Mixed

3 Own house/ rented house Own / Rented

4 Lighting Sufficient / Not sufficient

5 Ventilation Satisfactory / Not Satisfactory

6 Number of Rooms

7 Over crowding Yes / No

8 Kitchen Separate / Not separate / outside

9 Smoke vent Present / Absent

10 Latrine Present / Absent

11a Drinking water source Public tap / Tube well / Tap at home /Others

11b Distance of source of drinking water

12 Disposal of sullage Soakage pit / kitchen garden / indiscriminate / Public drains

13 Disposal of solid waste Manure pit / indiscriminate

14 Animals in house Cattle / Sheep / Others

15 Flies & Mosquitoes Yes / No

16 Breeding places Yes / No

17 Recreation

SCHEDULE FOR STUDY OF KNOWLEDGE AND BEHAVIOUR REGARDING

HEALTH AND DISEASE

Village: Family No:

Family Member interviewed :

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 “A STUDY ON HEALTH STATUS AND HEALTH PRACTICES OF SUGALI COMMUNITY IN KHAMMAM
MANDAL”
1. a) Can diseases be transmitted through unclean food and water? Yes / No

b) If yes name some diseases transmitted through unclean food and water

c) What are the hazards from flies and mosquitoes?

2. a) What is Diarrhoea ? : Loose motions/ Frequent motions /

Loose & Frequent motions / Do Not Know

b) What is the cause of Diarrhoea?

c) What is the treatment that you adopt in case of Diarrhoea?

d) Are you aware of ORS solution in the management of Diarrhoea? Yes / No.

3. a) What do you think about the following diseases

Malaria Tuberculosis HIV/ AIDS

Cause
Treatment
Prevention

4. a) Can diseases be prevented by immunization ? Yes / No

b) What are the diseases that can be prevented by Immunization?

c) Do you believe in immunization?

d) Are your children immunized? Yes / No.

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“A STUDY ON HEALTH STATUS AND HEALTH PRACTICES OF SUGALI COMMUNITY IN KHAMMAM
MANDAL”

SCHEDULE FOR STUDY OF KNOWLEDGE AND BEHAVIOUR REGARDING

HEALTH AND DISEASE (CONTND....)

5. a) When do you start breast feeding?

b)Do you give colostrum to the new born?

c) What is the first thing you give to a newborn?

d)Until what age would you continue breast feeding?

e) What do you know about exclusive breast feeding?

f) When do you think you can introduce solid foods?

6. Do you take any extra or special foods during pregnancy and lactation? Yes / No

7. a) What is the ideal number of children a couple should have ?

b) Can pregnancy be prevented? Yes / No.

c) If yes, how can pregnancy be prevented?

c) Can you mention some contraceptives?

Permanent:

Temporary:

8. a) What do you do whenever someone in family falls ill?

Home remedy / worshipping gods and goddess / herbal medicine / allopathic medicine / RMP/ Govt.

hospital / PHC / others

b) Where do you seek treatment when someone in the family falls sick

c) Who is the nearest healthcare provider?

d) Is there a PHC and / or Sub – Centre nearby ? Yes / No.

If yes, where?

e) Nearest referral hospital :

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 “A STUDY ON HEALTH STATUS AND HEALTH PRACTICES OF SUGALI COMMUNITY IN KHAMMAM MANDAL”

ELIGIBLE COUPLE SCHEDULE

Village : Family No. :

Name: Husband : Age (Yrs): Edn :

Wife : Age (Yrs): Edn :

Age of wife at first Child Birth

Age of wife at consummation of marriage:
Number of living Children Male: Female: Total:

Spacing between Ist & 2nd

2nd & 3rd

3rd & 4th

Age of Last Child (Years)

Family Planning : Adopted / Not Adopted

If Adopted, Method :

If not Adopted, reasons :

a. Family not yet completed

b. Want to have a male Child

c. Non-availability of facility - Explain

d. Any other - Specify

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 “A STUDY ON HEALTH STATUS AND HEALTH PRACTICES OF SUGALI COMMUNITY IN KHAMMAM
MANDAL”

SCHEDULE FOR PREGNANT WOMAN

1 Village 2. Family member

3 Name 4. Age

5 Obstetric formula G- P- L- A- D-

6a Weight (Kgs) : 6b. Height (cms):

7 Age of last living child (Yrs)

8a Date of termination of last pregnancy

8b Place of delivery Home / Institutional / Others

8c Nature of last delivery Normal / Abnormal / Assissted

9 Duration of present pregnancy (weeks)

10 Whether receiving antenatal care? Yes / No

If Yes, a) Source of ANC
b) Place of ANC
11 Tetanus toxoid immunization Not received / TT1/ TT2 / Booster

12 Whether received Iron Folic Acid in last three months? Yes / No

13 Whether receiving any food supplements from Yes / No

any source
14 Pallor: Mild/ Mod / Sev 15. Pedal oedema: Y/N 16. B.P. :

17. Presence of risk factors:

a) Elderly primi b) Short Stature

c) Grand Multi d) Moderate / Gross anaemia

e) Abortion in last pregnancy

f) More than three abortions in previous pregnancies

g) Still birth in last pregnancy h) Eclampsia

i) More than three still births in previous pregnancies

j) Bad obstetric History k) A.P.H.

l) Primi below 16 years. m) Previous LSCS

18. Any associated diseases affecting pregnancy : Kidney/Liver/Heart/Systemic/ Others

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“A STUDY ON HEALTH STATUS AND HEALTH PRACTICES OF SUGALI COMMUNITY IN KHAMMAM
MANDAL”
SCHEDULE FOR LACTATING MOTHER

1. Village 2. Family member

3. Name 4. Age

5. Weight (Kgs): 6. Height (cms):

7. General Physical Examination :

a) Built and nourishment

b) Pallor Mild/ Mod / Sev

8. Obstetric formula P- L- A- D-

9. Age of last living child (excluding present child)

10. Date of delivery

11. Place of Delivery : Home / Institutional / Others

12. Birth attendant : Untrained/Trained/Doctor

13. Nature of delivery : Normal/Abnormal/Assisted

14. Whether given any prelacteal feeds? Yes/ No

15. Whether given colostrum to the baby Yes/ No

16. Whether breast feeding the baby? Yes/ No

17. When was breast feeding started?

18. How long did/should you practice exclusive breast feeding?

19. When was complementary feed given?

20. Are you receiving any food supplements from any source?

21a. Whether received TT immunization during the pregnancy? Yes/No

21b. If yes, how many doses? TT1 / TT2 / Booster

22a. Did you receive any postnatal visits during first ten days? Yes / No

22b. If yes, Source :

23a. Whether received FP advice after delivery? Yes / No

23b. If yes, Source :

24. Whether received any IFA tablets during ante-natal period Yes/No

25. Whether received any IFA tablets during post-natal period Yes/No

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“A STUDY ON HEALTH STATUS AND HEALTH PRACTICES OF SUGALI COMMUNITY IN KHAMMAM
MANDAL”

UNDER FIVE CHILDREN SCHEDULE

1. Village : 2. Family No :

3. Name : 4. Age (in months) :

5. Sex : 6. Birth order :

7. Height (cms) : 8. Weight (Kgs) :

9. Attending Anganwadi / Nursery Y/N:

10. Whether breast fed : Yes/ No

11. Duration of breast feeding :

12. Whether any other milk given : Yes/ No

13. When was solid food introduced :

14. Whether any prelacteal feeds were given : Yes/ No

15. IMMUNIZATION STATUS:

a. BCG Y/N Scar Y/ N

b. POLIO Y/N

c. DPT Y / N / NA

d. HBV Y / N / NA

e. MEASLES Y / N / NA

16. If immunization is not accepted or completed, reasons:

17. VITAMIN “A” Prophylaxis

0 1 2 3 4 5 6 7 8 9 NA

18.Nutritional Status

19.General examination

20. Specific deficiency a. Pallor - Mild/ Mod /

Sev

b. Vitamin A deficiency - Y/N

c. IDD - Y/N

21.SYSTEMIC EXAMINATION:

I. RS - II. CVS -

22a. Present illness: yes/no

22b.If yes duration and nature

23. Sickness during past 1 month

24a. Name / type of disease /

24b. Duration

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“A STUDY ON HEALTH STATUS AND HEALTH PRACTICES OF SUGALI COMMUNITY IN KHAMMAM
MANDAL”
24c. Treatment for current illness if any : Received / Not Received

24d. Source of Treatment :

INDIVIDUAL SCHEDULE

1. Name : 2.Age (yrs): 3. Sex:

3. Education : 4. Occupation:

5. Complaints, If any :

6. General Physical Examination :

a) Built and nourishment

b) Pallor Mild/ Mod / Sev

c) Icterus / Cyanosis / Clubbing / Lymphadenopathy / Oedema / Goitre / None

d) B.P. e) Vision – Normal/Impaired f) Cataract Y/N

7a. Weight (Kgs) : 7b. Height (cms) :

8. Systemic examination

a. CVS b. RS

9. Personal habits:

a) Smoking:

b) Alcohol:

c) Tobacco Chewing:

d) Others:

10. Presence of any chronic diseases : Diabetes / HTN / T.B./ Leprosy / Filariasis /

Arthritis / Asthma/ Heart Disease / Others / None

11. History of fever in the last one month : Yes/ No

a) If yes, type of disease b) duration

c) Peripheral smear Y/N

d) Presumptive treatment Y/N

12a. Whether taking treatment : Yes / No.

12b. If yes, Source of treatment :

13. In case of default, reasons :

14. For females adult only

a) Menstrual history

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“A STUDY ON HEALTH STATUS AND HEALTH PRACTICES OF SUGALI COMMUNITY IN KHAMMAM
MANDAL”
Age at following events
b) Menarche
c) Marriage
d) Menopause

15. Remarks :

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