Series

Family study Pro-forma

Sathish Chandra MR1, Sharankumar Holyachi2, Veena V1

Introduction
Family study discussion is one of the integral parts of Post-graduate teaching. It helps the Post-graduate to
have a comprehensive understanding regarding the dynamics in a family, and how each of these has a bearing
on the health and disease states of the family members. Having gone through the process of family study
presentation during the post-graduation, the authors felt that available family study formats (1,2) were either in-
complete or were filled with lot of ambiguities or grey areas. Hence a need for an elaborate format was felt,
which can be accepted or can have consensus statement from majority of the Community Medicine Depart-
ments.
The authors accept that this pro-forma still remains incomplete. Hence all the Community Health Profes-
sionals from various institutes are requested to send in your suggestions, modifications, comments and criti-
cisms so that a single standard pro-forma can be put in use. The present publication is an attempt towards
collecting all possible details to be included in the pro-forma. Based on suggestions received from all the faculty
and other stakeholders the authors intend to bring out the addendums required to fill the pro-forma in the next
issue of the journal.
A. Area map
 Important landmark, approach roads and health care facilities.
 Type of road to approach the house: mud/ cement/ tar/ others
 Appropriate roads and position of house in relation to adjacent dwelling.

B. General information
1. Name of the locality: 2. Name of the PHC/ UFWC:
3. Name of local governing body: 4. Major occupation in the area
5. Name of the head of family/ responsible adult respondent:
6. Name of the person interviewed:
7. His/her relation to the Head of the family: 8. Duration of stay at this address:
9. Address:

Taluk: District: Contact no:

1
Assistant Professor, Department of Community Medicine, BGS Global Institute of Medical Sciences, Bangalore.
2
Assistant Professor, Department of Community Medicine, SS Institute of Medical Sciences & Research Centre, Davangere.
Correspondence to Dr Sathish Chandra MR (sathi.medico@yahoo.co.in)
The layout of the journal has been changed for this article facilitating better readability and understanding.
The editorial team along with the authors request the readers to kindly send improvements, suggestions, queries to the editorial e-mail id and all at-
tempts will be made to answer/incorporate them.
The subsequent parts will include explanations to each parts and replies of the author/editorial team for various comments received.
ANNALS OF COMMUNITY HEALTH | VOL 2 | ISSUE 2 | APR - JUNE 2014 | Page: 63
 10. Religion: Hindu /Muslim/ Christian/ Others
11. Caste: General/ OBC/ SC/ ST/ Others
12. Card holders: BPL/APL
13. Type of family: Nuclear/ Joint/ 3-generation 14. Number of family members:
Males: Females: No of married couples:

Occupation

Per-annum
Relation to

Educationd

Comments
Remarks/
Head of
Familya

Marital

Income
Statusc
Sl. No

Name

Sexb
Age
1
2
3
4
5
Total
a) Relationship to HoF: Self=1, Wife=2, Son=3, Daughter=4, Son/daughter in law=5, Grandchildren =6,
Mother in law /Father in law=7, Father=8, Mother=9, Others =10
b) Sex: Male=1, Female= 2
c) Single =1, Married =2, Widowed =3, Separated/ Divorced =4
Education: 1st=1, 2nd=2, 3rd=3, 4th=4, 5th=5, 6th= 6, 7th=7, 8th=8, 9th=9, 10th=10, PUC=11, Degree=12,
Semi-professional=13, Professional= 14, Not literate= 15
15. Monthly income of the family: Rs.
16. Monthly per-capita income of the family: Rs.
17. Socio-economic status of the family (Annexure-)
18. Schemes:
Widow Pension: Old age pension: Health insurance:
Other benefits etc.,

C. Monthly Expenditure pattern:

Sl.
Type of expenditure Amount (Rs) Proportion of total family income (%)
No
1 Expenditure on Food
Expenditure on House rent (if any)/
2
maintenance
Expenditure on Electricity, Telephone bill
3
and water charges
4 Expenditure on Medical needs
5 Savings
6 Debts
7 Other Expenditure. If any

D. Vital events in the past one year

Births Deaths Marriage Migration Divorce Adoption

64 ANNALS OF COMMUNITY HEALTH | VOL 2 | ISSUE 2 | APR - JUNE 2014

E. Health care services for the family
1. Availabilty
2. Accesibility
3. Affordabilty
4. Quality
5. Utilization.

F. External-environment (outside the house)

1. Any accident prone area: Yes/ No
2. Street lights: Present/ Absent
3. Stray animals: Present/ Absent
4. Open drains: Present/ Absent
5. Vector breeding sites: Present/ Absent
6. Any other significant observations:

G. Internal-environment (inside the house)

1. House Plan – preferably draw a rough sketch
 Legends on the right top
 Cross section at window level
 Set back: Present/ Absent

2. Type of the house: Owned/ Rented/ Leased out

a. Attached/ independent/ corner
b. Kuccha/ Pucca
c. Floor: Even/ Uneven ;Infestation of rodents: Present/ Absent
d. Roof: Thatched/ Tiled/ RCC/ Asbestos sheets/ Others; Leakage: Present/ Absent; Height:
e. Walls: material used;
Cracks and Crevices: Present/ Absent
Dampness: Present/ Absent

3. Size of the house:

a. Floor space of the house (in sq. ft):
b. Number of living rooms:
c. Per capita space in the house (in sq. ft):
d. Overcrowding: Present/ Absent

4. Ventilation:
a. No. of windows present:
b. No. of windows kept open:
c. Area of windows (in sq. feet):
d. No. of doors present:

ANNALS OF COMMUNITY HEALTH | VOL 2 | ISSUE 2 | APR - JUNE 2014 65

 e. No. of doors kept open:
f. Area of doors (in sq. feet):
g. Ratio of the window space to the floor area: 1/5th of the floor area: Yes/ No
h. Ratio of the doors + window space to the floor area: 2/5th of the floor area: Yes/ No
i. Cross ventilation: Present/ Absent
j. Indoor air pollution: Yes/ No

5. Lighting:
a. Natural: Adequate/ Inadequate
b. Able to read newsprint in any 2/3rd portion of the house: Yes/ No

6. Kitchen:
a. Separate/ In-living space
b. Floor type: Kutcha/ Pucca
c. Platform: Present/ Absent
d. Whether platform is used for cooking: Yes/ No
e. Clean/ Dirty
f. Fuel used: Wood/ Kerosene/ LPG/ Electricity/ Others
g. Storage of cooked food: Closed/Open Container
h. Storage of uncooked food: Closed/Open Container
i. Smoke outlet: Present/ Absent
j. Smokeless Chulha: Present/ Absent
k. Washing area for utensils: Present/ Absent
l. Disposal of sullage – open drain/ sokage pit/ kitchen garden.

7. Water supply (for drinking purposes)

a. Source: Private/ Common/ Public
b. Piped/ Bore well/ Open well/ River/ Tank/ Any other
c. Continous/ Intermittant
d. Distance between dwelling and source of water:
e. Method of collection:
f. Method of transportation:
g. Frequency of collection:
h. Storage vessel: Pitchers: Buckets- Steel/ Copper/ Aluminium/ Plastic/ Others
i. Storage: Open/ Closed
j. Household purification of water: Boiling/ Straining/ Filter/ Purifier (Aqua guard)
k. Method of drawing drinking water from container: By dipping vessel/ Ladle/ By tap
l. Source of water for other purposes: washing, gardening etc.

8. Bathing place:
a. Privacy: Present/ Absent
b. Light: Adequate/Inadequate
c. Maintenance: Good/ Poor
d. Accident prone areas: Present/ Absent
e. Drainage: Open/ Closed

9. Latrine:
a. Private/ Shared/ Community type
If shared, Whether it is sufficient: Yes/ No
b. Type: Flushable/ Water seal present
c. Utilized: Yes/ No
d. Children allowed or encouraged to defecate/ micturate near the house: Yes/ No
e. Distance of these toilets from dwelling place:

66 ANNALS OF COMMUNITY HEALTH | VOL 2 | ISSUE 2 | APR - JUNE 2014

 f. Maintanence: Present /Absent
g. Water supply: Continous/ No
h. Lighting: Present/ Absent
i. Hand washing practices (soap use): Yes/ No
j. Drainage: Septic tank/ Underground Sewerage

10. Solid waste management:

a. In the house:
i. Container used: Yes/ No
ii. Waste containers in the house: Lid/ No lid
iii. Segregation of wastes in to bio-degradable and non-biodegradable: Yes/ No
iv. Frequency of disposal : Daily/Alternate day/ Weekly/ Other
b. In the area: Present/ Absent
i. Distance from the house:
ii. Door to door collection: Done/ Not done
iii. Container: Present/ absent.
iv. Frequency of evacuation: Daily/Alternate day/ Weekly/ Other
v. Describe common waste collection point: (Eg: manure pit etc.)
vi. Accesibility to animals:

11. Pets in the house: Present/ Absent

12. Vector menace in the family: Flies/ Mosquitoes/ Rats etc.,

13. Dietary practices:

a. Type of diet: Vegetarian/ Non-vegetarian
b. Staple diet: Ragi/ Wheat/ Rice/ Maize/ Others
c. Frequency of procurement of raw food: Daily/ Weekly/ Monthly
d. Average no of meals per day consumed by all family members:
e. Frequency of procurement: Perishable/ Semi-perishable/ Non-perishable items
f. Storage: Perishable/Semi perishable/ Non- perishables items
g. Method employed for cooking: Roasting/ Frying/ Boiling/ Steaming/ Soaking/ pressure cooking
h. Vegetables washed thoroughly and not merely rinsed in water
i. Vegetables / Fruits cut: before washing/ after washing.
j. Food items prepared on special occasions
k. Food faddism- Likes/ Dislikes:

14. Calculate the consumption units for the family

a. Estimate the amount of food items used by the family per day.
b. Estimate the amount they should actually be using according to the RDA.
c. Then compare the above two and calculate the deficiency or excess;
d. Total consumption units (CU) of the family:___________

Sl Required Intake
Dietary items Recommended Comment
no. (gms) (gms)
1 Cereals 460 x CU
2 Pulses 40 x CU
3 Green leafy vegetables 40 x CU
4 Roots and tubes 50 x CU
5 Other vegetables 60 x CU
6 Milk 150 x CU
7 Sugar and jiggery 30 x CU
8 Oils and fats 40 x CU
Comment: Deficiency/ excess in:

ANNALS OF COMMUNITY HEALTH | VOL 2 | ISSUE 2 | APR - JUNE 2014 67

 Sl Family members Required calories & Intake Comment
No. Proteins calories & Proteins
1
2
3

H. Family health
General health
Anthropometry

examination
(present &

Waist Cir
Chest Cir
Head Cir
History

Hip Cir
Weight

MUAC
Sl. No.

Height

WHtR
Name

Other
WHR
past)

BMI
1
2
3
Health problems in any of the family members: High risk individuals in the family: Pregnant
Lactating Under-5 child Infant

I. KAP REGARDING HEALTH AND DISEASE (Ask about general knowledge about common diseases,
attitude towards health seeking behaviour and practices regarding treatment and prevention) related to causa-
tion and transmission of diseases.

1. Knowledge: (Note: These are Sample questions should be used appropriately)

a. Do you know about________________ disease - Yes/ No
b. Do you know how we get _______________ disease - Yes/ No
c. Do you know how it can be controlled?

2. Attitude:
a. Are you willing to follow the same system of medicine for treatment- Yes/ No
b. Are you willing to consult the doctor at regular intervals- Yes/ No
c. Are you willing to follow the same advice given by the doctor- Yes/ No

3. Practice:
a. Which system you are following now for treatment- Allopathy/ Ayurveda/ Unani/ Siddi/ tra-
ditional healer
b. Are you consulting your doctor at regular intervals- Yes/ No
c. Are you taking your medications regularly- Yes/ No

J. Social and Cultural practices

1. Antenatal Period:
a. Withholding food items during antenatal period:
b. Delivery at home itself:
c. Special diet
d. Physical activity
e. Antenatal care taken routinely or not?
f. Any other significant custom.

68 ANNALS OF COMMUNITY HEALTH | VOL 2 | ISSUE 2 | APR - JUNE 2014

 2. Postnatal Period:
a. Lactation
i. Special diet
ii. Physical activity
iii. Any other significant custom

b. Puerperium.
i. Withholding food items during postnatal period:
ii. Any other significant custom

3. Infancy and Childhood

Child rearing practices
a. Application on the umbilical cord
b. Colostrum given or not?
c. Special practices such as oil bath and applying kajal.
d. Pre-lacteal feeds.
e. Method of feeding such as with bottle or spoon
f. Usual age at which is weaning is started
g. Usual weaning foods.

4. Regarding childhood illness.

Disease Can it be prevented? If disease occurs, what measures would
If yes, how?
Yes/No you take?
Tuberculosis
Measles
Tetanus
Diphtheria
Whooping
cough
Diarrhoea
Typhoid

K. Psychosocial environment in the family.

1. Check if the family is well adjusted in the community? If not, what is the likely reason?
2. Any cause of psychological stress.
3. Is there any cause for psychological stress?
4. Unemployed youth
5. Unmarried girls
6. Addiction in any of the family member
7. Problem due to financial difficulty
8. What are the recreational facilities for children?
9. Availability of Self Help Group (SHGs) like Stree Shakti Samaj,
10. Any physically or mentally handicapped persons in the family
11. Any other (specify)

L. SUMMARY (in the order of priority)

This is the family of Mr. X residing in __________ belonging to ____________ socioeconomic status.
Problems identified in the family are

1. Social
2. Economic
3. Environmental

ANNALS OF COMMUNITY HEALTH | VOL 2 | ISSUE 2 | APR - JUNE 2014 69

 4. Dietary
5. Medical
6. Health demands (perceived by the family members) are______________
7. Health needs (perceived by the physician or policy makers) are______________
8. The vulnerable individuals identified in the family are________________

Neonate/Infant/Under five/Adolescent/Antenatal woman/Postnatal woman/Geriatric/any specific disease

1. Relevant history about illness:
2. Examination
a. General (including vital signs)
b. Systemic

M. Plan of management and suggestions

1. To specific individuals

2. To the family on the whole

3. To the community at large

N. National programmes & Health legislations applicable for the family

ACKNOWLEDGEMENT
The authors sincerely acknowledge all the faculty and PGs of Department of Community Medicine Kempe-
gowda Institute of Medical Sciences, M S Ramaiah, St John’s Medical College, BGS Global Institute of Medical
Sciences, Bangalore and SS Institute of Medical Sciences, Davangere for all their suggestions. Without the guid-
ance of the entire senior faculty during the days of our own family study presentations, this manuscript would
not have been a reality!

REFERENCES:
1. Mathur JS. A guide book for family and field work in 3. Sunderlal, Pankaj, Adarsh. Textbook of community
social and preventive medicine. medicine: preventive and social medicine. 2 nd ed. CBS pub-
2. Park K. Park’s textbook of preventive and social lishers and distributors; 2007.
medicine. 22nd ed. Jabalpur: M/s Banarasidas Bhanot Pub-
lishers; 2013.

70 ANNALS OF COMMUNITY HEALTH | VOL 2 | ISSUE 2 | APR - JUNE 2014