This document appears to be a form used to collect information on family health surveys conducted by the Department of Community Medicine in Madurai, India. The form collects information in multiple sections, including general family information, environmental sanitation, maternal health, child feeding practices, immunization, health care utilization, and details on family members with diabetes or hypertension. It requests names, ages, education levels, occupations, family relationships, and other health-related details. The form uses codes to standardize response options for questions.

1. Form ID:
1
Department of Community Medicine
VMCH & RI, Madurai
Family health survey
General info
1. House no. / EB no.
2. Street or area name
3. Name of head of the family
4. Education of the head of the family
5. Occupation of the head of the family
6. Total family income Rs.
7. Total no. of family members
8. Type of the family 1. Nuclear 2. Extended
9. Religion of the family 1. Hindu 2. Islam 3. Christianity
Family members
No. Name Age
(yr)
Sex Relation
with
head
Marital
status
Edu Occu Income
Per
month
1. 0
2.
3.
4.
5.
6.
7.
Codes:
Sex:
1-Male,
2-Female
Relation with head
0-Head
1-Wife
2-Husband
3-Son
4-Daughter
5-Son in law
6-Daughter in law
7-Grand children
8-Other (uncle, aunt, nephew, niece etc.,)
Marital status:
1-Never married
2-Currently married
3-Divorced
4-Widowed
5-Separated
Education:
1-Not yet started school
2-Still studying
3-No formal schooling but can read and write
4-Completed primary school (1-5 std)
5-Completed middle school (6-8 std)
6-Completed secondary school (9-10 std)
7-Completed higher secondary school (11-12 std)
8-Completed diploma
9-Completed college degree
Occupation: (only for persons aged 14 and more)
1-Still studying or student
2-Unemployed (not studying, not working)
3-Retired from work (for persons aged >60 years)
4-Unskilled
5-Semiskilled, 6-Skilled
Income:
Ask about the usual income per month
Add income from rent and other sources to the total family
income.

2. Form ID:
2
Environmental sanitation
10. Type of house
1. Kutcha
2. Pucca
3. Semi-pucca
11. No. of living rooms
12. Overcrowding
1. Present
2. Absent
13. Ventilation
1. Adequate
2. Inadequate
14. Lighting
1. Adequate
2. Inadequate
15. Kitchen location
1. Separate room
2. Within a room used for other
purpose
3. Outside the house
16. Kitchen type
1. Smokeless
2. Smoky
17. Bathroom
1. Present within house
2. Present outside house
3. Absent
18. Sanitary latrine
1. Present and using
2. Present but not using
3. Absent
19. Drainage
1. Proper
2. Improper
20. Source of drinking water
1. Hand pump within house
2. Public hand pump
3. Municipal pipe in house
4. Public tap
5. Well within house
6. Public well
7. Pond
8. Mineral/RO water bought from
shops in cans
9. Tube well within house
10. Others:____________________________
Over crowding criteria
Rooms Persons
1 2
2 3
3 5
4 7
5 10

3. Form ID:
3
Maternal health (fill only for married women in 15-45 years age group who have been pregnant in the last five years)
Name Age at
marriage
No. of
pregnancies
in last 5
years
(including
abortions)
No. of
children
born in
last 5
years
Whether TT
taken during
last pregnancy
Whether IFA
taken during
last pregnancy
(approx.. 100
tablets)
Place of delivery
of last pregnancy
Last
pregnancy
outcome
Present status of
last child born alive
(fill only if alive in
prev. column)
1 1. Yes
2. No
1. Yes
2. No
1. Hosp
2. Home
1. Alive
2. Stillbirth
3. Aborted
1. Alive
2. Dead
2 1. Yes
2. No
1. Yes
2. No
1. Hosp
2. Home
1. Alive
2. Stillbirth
3. Aborted
1. Alive
2. Dead
3
4
5
Currently pregnant women (fill only if there is a currently pregnant women in the house)
Name Which trimester?
Registered or
not so far?
No.
of
visits
TT1 TT2 TT Booster
IFA received
so far or not
Choice of
delivery place
1 1. First
2. Second
3. Third
1. Yes
2. No
1. Yes
2. No
1. Yes
2. No
1. Yes
2. No
1. Yes
2. No
1. Home
2. Govt.
3. Pvt.
2
3

4. Form ID:
4
Child feeding practices (fill only for children below 2 years)
No. Name Age
(mo)
Prelacteal
feed
Type of
prelacteal feed
given
Breast feeding Type of weaning food
Initiation time EBF time
When stopped
given at start
(hours after
(mo)
completely (mo)
birth)
1 1. Given
2. Not
given
1. Sugar water
2. Honey
3. Animal milk
4. Holy water
5. ___________
99. Not at all
given
1. <30 min
2. 30 min-1hr
3. 1-4hr
4. >4hr
99. Not at all
given
1. <6 months
2. >6 months
99. Not at all
given
1. <6 months
2. 6 mo-1 yr
3. > 1 year
99. Not yet started
1. animal milk
2. rice
3. dal
4. vegetable
5. kichdi
6. cerelac, nestum,
lactogen, milk powder
7. others
____________________
2
3
Immunization (fill only for children aged 12 to 24 months at present)
No. Name
Whether immunization
card present
BCG, OPV
0 dose
OPV, Pentavalent
Measles
Reasons: If any
1 2 3 vaccine is not given
1
1. Yes
2. No
1. Yes
2. No
1. Yes
2. No
1. Yes
2. No
1. Yes
2. No
1. Yes
2. No
2

5. Form ID:
5
Health care utilization
No.
When some one in your family falls sick, where do you go
for treatment? (Write the most common option)
1. We don’t go anywhere, prefer home remedy
2. Local healer
3. Govt. hospital
4. Pvt. qualified doctor
1 Reasons for preferring this option (only for options 2,3,4)
1. Known to us
2. Comfortable
3. Cheap
4. Recommended by friends or relatives
5. Others _______________
Diabetes and Hypertension
No. Name What disease?
Whether currently
taking treatment?
What type of
treatment?
Regularity of treatment
1
1. HTN
2. Diabetes
3. Both
1.Yes
2. No
1. Allopathic
2. Alternative medicine
3. Both
1. Regular
2. Irregular
2
3