GOVT. NURSING COLLEGE N.S.C.B.
JABALPUR
FAMILY HEALTH
FOLDER
SESSION -........................................
Name of the Student
Year of the Study
Signature of Student
Signature of Supervisor
1
Date
FAMILY HEALTH RECORD
Social system:
I- Family Identification
1. Head of the family :
2. Address :
3. Telephone No. :
II- Family Characteristics
1. Type of Family : Nuclear / Joint
2. Size of the family :
3. Religion : Hindu / Muslim / Sikh / Christian / Others
4. Diet : Vegetarian / Non Vegetarians
III Housing & Sanitary Condition
1. Type of House : (a) Own/Rental (b) Pucca/Kuchcha/tiles/mixed
2. No. of Room : 1/2/3/4/5/6/7
3. Ventilation : Natural/artifical; lighting : electricity/kerosene lamp
4. Cleanliness :
5. Water supply : weel/tap water/hand pump / pond/public supply
6. Latrine : service type / sanitary/ open air
7. Drainage : Open/closed/soakage pit
8. Cooking Fuel : firewood/kerosene/gas/cow dung
9. System of waste disposal: stamp/manure pit/public carrier / burning
10. Other relevant details : .......................................................................................
Family Composition
Death
Name of
S. DOB/ Health in the
Date the Family Relationship Sex Education Occupation
No. Age Status last 5
members
yrs
1
2
3
4
5
Total Income: ...........................................................................................................................
Per Capita Income: ..................................................................................................................
IV - Health Habits
Health Habit Occasional Addiction
Smoking
Alcohol
Drugs
Any other
V- Health status record
S. Needs / Treatment Referral Health
Name
No. Problem details service if education
2
Hospitals / needed
Home follow-up
VI - Health Problem felt by the family: ..................................................................................
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VII - Health Problems Identified by the Investigator: ......................................................
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VIII- Immunization Status of Children
Name OPV DPT Any
S. Vita A
of Age Sex BCG MMR other
No.
Children I II III Booster I II III Booster Solution
specify
1
2
3
4
VIII (A) - Covid-19 vaccine
S
No. Member Dose 1 Dose 2 Date
1.
2.
3.
4.
5.
IX - Vulnerable Family Members
Health Problem
S.No. Family Members Number
Assessment Identified
1 Infant
2 Children Between 6 yrs
3 Antenatal Mother
4 Lactating Mother
5 School Children
6 Adolescent
7 Elderly
8 Challenged Physically /
Mentally
3
X - Health and Illness History
(i) Maternal and child health
Mother
- Pregnancy at present (yes/no) .....................................................................................
.......................................................................................................................................
- If yes, No. of Pregnancy: .............................................................................................
.......................................................................................................................................
- Duration of Pregnancy: .................................................................................................
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- TT Vaccination: ............................................................................................................
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- Anemia (Observed / not present): ...............................................................................
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- Any other information: .................................................................................................
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About Maternal Health
- Children :
- Number of children : ......................................................................................................
- Number of Children (Under 5 year) : .............................................................................
(ii) Family Planning
- Eligible Couple : ............................................................................................................
(Observed / Not observed) ............................................................................................
- Users of Contraceptives: ..............................................................................................
(If yes, give number of users)........................................................................................
- Preference of contraceptive: ........................................................................................
(Nirodh / Pills / Copper T etc.) ......................................................................................
- Willingness for permanent sterilization : .......................................................................
(Yes/No/Half Hearted) ..................................................................................................
(iii) Record of vital statistics (Brief description of family births and deaths)
.......................................................................................................................................
...............................................................................................................illness in family
- In illness, where family go for Treatment? Specific therapy (Allopathy/ Ayush :
Ayurvedic, Yoga, Naturopathy, Unani, Sidha and Homeopathy) .......................
............................................................................................................................
- If any member is taking continue treatment : .....................................................
............................................................................................................................
Any surgical history, if occurred : .......................................................................
............................................................................................................................
Details of members suffered with communicable diseases: ............................
............................................................................................................................
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(iv) Present health status of the family: .............................................................................
.......................................................................................................................................
(v) Health Resources : .......................................................................................................
.......................................................................................................................................
- Health Centre SC - Barods, Belkhadu / PHC - Katangi / CHC - Patan,
Panagar / Hospitals / Urban Communities - Ghamapur, Madhotal .................
............................................................................................................................
............................................................................................................................
- Sources of Health care providers : ..................................................................
............................................................................................................................
- Voulantary health agencies or NGO's of Health care sector...........................
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XII Learning Outcome
- Knowledge : ..................................................................................................................
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- Skill : .............................................................................................................................
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- Attitude : .......................................................................................................................
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XII Summary .......................................................................................................................
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XIV Conclusion .....................................................................................................................
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XI Family Care plan in order of Priority
S. Health Remarks of
Name Age Sex Nursing Goal Nursing Diagnosis Nursing Intervention Evaluation
No. Needs Supervisor
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XI Family Care plan in order of Priority
S. Health Remarks of
Name Age Sex Nursing Goal Nursing Diagnosis Nursing Intervention Evaluation
No. Needs Supervisor
8
XI Family Care plan in order of Priority
S. Health Remarks of
Name Age Sex Nursing Goal Nursing Diagnosis Nursing Intervention Evaluation
No. Needs Supervisor
9
Health Education
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