This document contains a survey forma used to collect community health data. It collects information on family demographics, household characteristics, socioeconomic status, health care utilization, mother and child health, communicable/non-communicable diseases, vital events and needs/problems in the community. The survey collects both qualitative and quantitative data on these topics to assess community health and identify areas for nursing intervention.

1. NIGHTINGALE INSTITUTE OF NURSING
COMMUNITY HEALTH NURSING
SURVEY PERFORMA
Community Setting:-
Date of Data Collection:-
Name of the Interviewer:-
A. FAMILY IDENTIFICATION DATA
• Name of the area: Rural________________ Urban________________
• Name of the health center: - _____________________________________
• Name of the head of the family: -____________________________________
• Address: -_____________________________________________________
• Type of family: - Joint_________Nuclear:_________________any other_____
• Total number of family members: -________
• Religion: -___________(Hindu/Muslim/Sikh/Christian, any other)
• Caste:-_______________________(Brahman/Jaat/Harijan/any other)
B. FAMILY COMPOSITION
S.No Name of the
family
members
Relationship
with HOF
Age Sex Marital
status
Education Occupation Income Religion Health
status
Immunizat
ion status
Remarks
M U D W

2. C. HOUSEHOLD CHARACTERISTICS
1. General appearance: clean___________dirty_________
2. Type of house: Pucca______Kuccha_______ (own house/ rented house)
3. Number of rooms: ______________ (adequate/inadequate)
4. Number of person per room: ___ Overcrowding: Present_____Not present
5. Ventilation: Adequate________Inadequate:_____________ (Check for cross ventilation)
6. Electricity: Yes_________ No__________
7. Source of light: Natural_________ Artificial:________Both:__________
8. Source of water supply: - Community supply/Household supply/ Tap/Hand Handpump/Well.
9. Place for washing/bathing__________ (separate/ any other (specify)
10. Kitchen facility:-……………separate, Verandha/one corner any other
• Cleanliness…………………………clean/Moderately clean / dirty
• Chula……………………………. Gas/ electric/ oil mode/ coal /any other
11. Excreta disposal:-
Household latrine__________ Community latrine____________Open defcation___________
12. Spillage water disposal:-
Soakage pit________Open drainage_____ Closed drainage_________
13. Refuse disposal:
Dustbin______Fielddisposal_____Burning_____Tipping_____Composting______
14. Community awareness______________ (yes/no)
14. Sources of environmental pollution_________________ (air/ water/ soil and noise)
D. MODE OF TRANSPORT
I. Bus service Available/ not available
II. Own vehicle If any, specify
III. Others
E. MEANS OF COMMUNICATION
• Radio: yes/ No
• TV yes/ No

3. • Internet yes/ No
• Newspaper yes/ No
• Magazine yes/ No
• Smart phones yes/No
• Landline phones yes/No
F. SOCIO-ECONOMIC STATUS
1. Main occupation of the family: ______________________
2. No. of earning members________________________
3. Source of the income: ___________________________
Total income of family: __________ Per capita income: ____________ (low/middle/high)
3. PET ANIMALAND POULTRY: _____________
• Pet animal kept in premises__________(yes/no)
• Pet animal: Dog/Cow/Goat/Buffalo/any other________________
4. Habits affecting health: ------tobacco__________- smoking___________-- alcohol________drugs
__________ Sedentary life style___________
Note: ___________________
F. NUTRITIONALAND FOOD HYGIENE
General nutritional assessment
1. Food preference: vegetarian: ________ non vegetarian:_________egg vegetarian_____ mixed_
2. Menu for a day: ___________
3. Staple/ common food of house: ________________
4. Number of meals per day: _____________________
ANY NUTRITIONAL PROBLEM
S.NO. NUTRITIONAL PROBLEM NAME AGE/SEX REMARKS(YES/ NO)
1. Anaemia
2. Malnutrition
3. Goiter
4. Fluorosis

4. 5. Worm infection
6. Obesity
7. Vitamin deficiency: if yes specify
8. Food allergy
9. Others
G .HEALTH CARE UTILAZATION
Practice and availability of health services
• Traditional/house remedies:______________
• Goverment hospitals/Health centers:________________
• Privates hospitals/clinics------------------------
• Outlook on causes of disease:- Rational / cures of God / evil spirit/ any other
• Outlook of causes of death: Rational/ god wish/ any other
• Outlook of prevention of disease: Rational/religions
• Awareness of MCH and PHC centre:- Rational / religion
• Type of service available:- Satisfied / not satisfied
• Have you ever visited the centre:- Yes/No
• If yes give reason for visit:-
• Any other medical facility:- Yes /No
• If yes mention the services
• Have you ever availed that services:- Yes/No
H. MOTHER AND CHILD HEALTH
A. Mother
• No. Of pregnancy: ____________
• Type of delivery:_______________(NVD/LSCS/Others)
• Place of delivery:_________________(home/institutional)
• Prenancy at present__________Yes:____________ No: ________(registered or not)
• Regular follow-up______________(yes/no)
• If yes, duration of pregnancy: _________________
• Injection TD taken___________(yes/no)

5. • Presence of anaemia Yes or no (Hb 8 g or below) Yes:____________No:____________
• Taking treatment (iron/folic acid/calcium) Yes: _________ No:____________(specify if any other)__________
• Any other diseases______________
B. Children (0 to 5 year)
• Presence of anaemia Yes:_____________ No:____________
• Under treatment for anaemia; Yes: ___________- No:___________
• Malnutrition: Absent/Mild/Moderate/Severe_____________
• Getting nutritional supplements: Yes:__________ No___________
C Immunization status:
S. NO. BCG PENTAVELANT TD OPV MR DPT IPV RVV TYPHOID VITAMIN A BOOSTER ANY
OTHER
D. FAMILY PLANING
1. No of living children: _______- male_______- female__________
2. Age of last child ____________Years_________ months__________
3. Eligible couple for FP ________ Yes___________No__________
4. Use of family planning methods__________________________
S.NO. F.P. METHODS PRESENTLY
USING
DISCONTINUED SINCE
WHEN
REASON FOR
DISCONTINUING
REMARKS
1 VESECTOMY
2 TUBECTOMY
3 IUD
4 ORAL PILS
5 CONDOM
6 DIAGPHRAM

6. 7 JELLY
8 FOAM TAB
9 OTHERS
None of the method ever used, reason______________________________________
I. GERIATRIC POPULATION ASSESSMENT
Total no of geriatrics: ______________________
1. Food preference: vegetarian_____________ non vegetarian___________ mixed______________
2. No. of meal per day: ________________
PERFORMA FOR ELDERLY HEALTH ASSESSMENT;
S. NO. HEALTH PROBLEMS 1ST
ELDERLY
2ND
ELDERLY
3RD
ELDERLY
1. Impaired hearing
2. Impaired vision
3. Immobility
4. Incontinence
5. Joint problems
6. Cardio vascular diseases
7. Respiratory diseases
8. DM
9. HTN
10. Neurological diseases
11. Psychological disorders
12. Accident and injuries
13. Dental problems
14. Memory issues
15. Cancers
16. Any other
• Financial support during illness:_________________________________________
• Care provider during illness_______________________________________

7. • Living with family or not__________________________
J. COMMUNICABLE/NON-COMMUNICABLE DISEASES PREVAILING IN THE FAMILY:
S.NO DISEASE NAME AGE/
SEX
SIGN&
SYMPTOMS
DIAGNOSED/UN
DIAGNOSED
UNDER
TREATMENT
SINCE WHEN
TREATMENT
DISCONTINUED
SINCE WHEN
REMARKS
1 TB
2 LEPROSY
3 MALARIA
4 FILARISIS
5 S.T.D
6 MEASLES
7 CHICKEN POX
8 DM
9 HTN
10 CHD
11 RHD
12 ASTHMA
13 ANY OTHER
K. RECORDS OF VITAL EVENTS (BIRTH AND DEATH)
In villages reporting of births and deaths are recorded by village Dasis, Chowkidars. When a community health
nurse visits the home she comes to know about the birth and deaths taken place since her last visit.
The importance of registering these events are:
1. To provide services to new born and mothers to teach her own and child care.
2. To find out the cause of death, necessary and a part of communicable surveillance, particularly in infants,
pregnancy and child birth.
3. To teach the community where and why deaths and births to be registered, Births and deaths may be recorded as
follows:

8. BIRTH RECORDS (WITHIN 1 YEAR)
DATE OF
BIRTH
NAME OF
CHILD
AGE/SEX NAME AND ADDRESS
OF PARENTS
NAME OF
PERSON
ASSISTED IN
BIRTH
CHILD ALIVE
YES/NO
WT. AT BIRTH
AND PLACE OF
DELIVERY.
DEATH RECORDS (WITHIN 1 YEAR)
S.NO. NAME SEX AGE AT THE
TIME OF
DEATH
PLACE OF
DEATH
DATE OF DEATH/
CAUSE OF DEATH
NAME AND ADDRESS OF PERSON
REPORTING DEATH
_______________________________________________________________
L. LIST OF NEEDS, PROBLEMS AND NURSING DIAGNOSIS
A. NEEDS
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………

9. …………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
B. PROBLEMS
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
………………………………………………………………………………………………………………….
C. NURSING DIAGNOSIS
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
Date of data collection………………………. Signature of supervisor………………