MOTHER THERESA POST GRADUATE AND RESEARCH INSTITUTE OF HEALTH SCIENCES
COLLEGE OF NURSING,
COMMUNITY HEALTH NURSING – FORMAT FOR FAMILYCASE STUDY/CARE NOTE
I. Student Profile
II. Individual profile( identification data)
Head of the family :
Address :
Age :
Sex :
Occupation :
Classification :
III. Family profile
S.No Name Relationship Age Sex Educatio Occupation Income Health
With HOF n status
IV. Family health status(PRIORITY)
NAME AGE SEX HEALTH PRIORITY
STATUS
V. Pedigree with keys(3 generation tree)
VI. Home observation
A. Home setting ( plan of house)
B. Home observation/ Environmental factors
C. Roof : tiled/ thatched/ terraced/ hut
D. Walls : mud/brick/plaster cement/mud white wash
E. Floor : mud/cow dung smeared/tiled/cement plastered
F. Ventilation : well ventilation/cross ventilation/ inadequate
G. Lighting : natural/artificial – specify
H. Smoke outlet : present/absent
I. Water supply : municipality/well/tank/pond- specify
J. Storage of water : type of container- specify, closed/open
K. Cooking facilities : mud chulah/smokeless chulah/kerosene
Stove /gas stove/electric stove
L. Washing place
for dishes : where/water drainage-specify
M. Bathroom : where/water drainage-specify
N. Latrine : present/absent- type- specify
COLLEGE OF NURSING,
COMMUNITY HEALTH NURSING – FORMAT FOR FAMILYCASE STUDY/CARE NOTE
I. Student Profile
II. Individual profile( identification data)
Head of the family :
Address :
Age :
Sex :
Occupation :
Classification :
III. Family profile
S.No Name Relationship Age Sex Educatio Occupation Income Health
With HOF n status
IV. Family health status(PRIORITY)
NAME AGE SEX HEALTH PRIORITY
STATUS
V. Pedigree with keys(3 generation tree)
VI. Home observation
A. Home setting ( plan of house)
B. Home observation/ Environmental factors
C. Roof : tiled/ thatched/ terraced/ hut
D. Walls : mud/brick/plaster cement/mud white wash
E. Floor : mud/cow dung smeared/tiled/cement plastered
F. Ventilation : well ventilation/cross ventilation/ inadequate
G. Lighting : natural/artificial – specify
H. Smoke outlet : present/absent
I. Water supply : municipality/well/tank/pond- specify
J. Storage of water : type of container- specify, closed/open
K. Cooking facilities : mud chulah/smokeless chulah/kerosene
Stove /gas stove/electric stove
L. Washing place
for dishes : where/water drainage-specify
M. Bathroom : where/water drainage-specify
N. Latrine : present/absent- type- specify
