FAMILY PROFILE DATA Primary Health Centre: Community Health Centre Lan Name of the Village: 1. IDENTIFICATION INFORMATION OMG NS Head of family-Name: _A/ie, Kedhan Vaclav 2YL Occupation : a Phe d a a address Qackg Type of family: Nuclear [—] Joint [=F Religion: Hindu (L-7] Muslim Christian [ Any other ] 2. HOUSING CONDITION rae L.Type of House: Completed [__] Independent [-—ATileld sheeted Hut Owned 1.Rooms Adequate [LJ Inadequate >7] 3. Kitchen Separate [LJ ‘to room. [__] 4. Fuel Used Gas (L4 Fire Wood [__] Electricity 5. Ventilation (eT Inadequate [—_] 6. Bath Root Separate Common [= 7. Lighting: Electricity [= Oil Lamp 8. Drainage: :open L_] Close ct 9. Water Supply: Tap/Fland Pump Well Chlorined.- Y€5/No Open Tank Chlorinated YES/No 10 Toilet : Own Public Open field 11 Disposal of Waste: Composing [__] Burning [1 Buying separate [=f Within the House 12 Cattle Shed ia2 HH 3. FAMILY COMPOSITION T Health |lmmunization| Relationship Occupation 1 SN) Name | withtead of | Ase Sat), Mlucation | Qccups status status the Family rae Head | fr Male! ce Jeol Fem Feeley ——— Hedeon | Un boli] Heese Weal fi twife 58 | female eed cele Poamele Wea Va Wess Sey | yo | Male (OR over exe Past Teas Head? Healt! Done | Lexeun |@ 38 Lonel | rts wole =| my | nn cl Unley Sansa | Pade tq Hemel! pve Whadbet_p Bene | al) a * Wikreg| 186m | 17 [Mule | 07 haded Hewlhy ene | 4. TRASPORT AND COMMUNICATION FACILITIES A. Transport 8. Communication Media own vivo ese (5 Tome (Wheeler Telephone + [Joy Bus (sete private] Television eo ‘Autos Taxies train Radio GO ‘spaper/Magazines[—] [a] Post & Telegraph =] [- 5. LANGUAGES KNOWN Mead [Mews ya 4 fray tins EF anyother E] = 6.8) NUTRITIONAL PATTERN. Veretarian [ET Won Vegetarian (] Staple Food Me] weet CO) me 3 ed DS Vegetables Grove (EE | Parcel Quantity used per day:.2- kg Mil = Quantity used per day ...Qon tees Non Vegetarian Dish: Specify... How often(B) NUTRITIONAL STATUS OF FAMILY MEMBERS Name of the Member | Nourished/nder Nourished Malnutrition UA ey = yal” Newrisher! 7. RECORD OF ILLNESS Name of the Member | Ag is Gund Maly ¢ L “fp, see a ey |e Mness | Duration | Main Investigation | Treatment Characteristics | done i L 7, PREGNANT WOMAN Name (bape | Gravida | No. of Children | Whether Registered in | Receiving Iron &Para_| Living Hospital Nursing Home _| and Folio Acid 9, ELIGIBLE COUPLES Name ‘Age [ Family Planning Method | Notinterested in] Willing to use Family Adopted _| Family Planning | Planning method IN CASE OF SICKNESS WHERE DO YOU GO FOR TREATMENT Name /Primary Health Centre Private Nursing Home st \ligenous Doctor /Dai Community Health Centre Indigenous Doctor/| DS.andj : wn feed 3 obra fig yao good | zh 770 + pooped | powprd Typovadmaf 281700 | he Gay Ap awoang uonenread pea | amp remy.) RY sean /aan: quatilssassy P Er NV Id duvod ONISUNN tfNURSING CARE PLAN Evaluation Outcome ‘Nursing Diagnosis Objective/ Goals ‘Nursing Interventions | | ~~ Assessment | BEE | Bleed PE watch, [EIS | Coal i aden | Ye ited ted edith B | actasveof have feef fo LAS Hesol * Cheth tee. patrend lseakeness Sarno Volume. VeAl Seip pee? uel. bvtz{ eu : | By ebtes | careckuess o Mont, (aot pat rake ah a ic eI) a | nacbehedn.NURSING CARE PLAN x Objective7 Goals [Wa toe have fee/ Yo fet he «Cheek toe. | pPrhent weakness : ; ef well. bvex{euceof | aoe wbpeetic ds OMI aud i ebsesvec! ee G Monte! ee patient Cenolf | | Hflén wiolene | casfpet ~ef by Bay | le Gure | ane! Ce a 7 fee | Coss | bef | NURSING CARE PLAN Peete ie__ — | afb PO . lwapr lip | ap9P? TF Duran | | zperord * feorayrown | Eafe r7yprm \ rg 22 V9 PAO | are earfazOMro coprrrupty * bree 004 | ped 0 aby poe PARE | Caavorge 8 « fon JG . pap sper? capa aag Prt ROE APA frorg | PSvo | prarrngyrave Cara Rr yp9 | prraypaon >og-9 070 _ oupey” a Kg ES luop OW ‘ darfasfon 2 v2 app Fenn? f A | , ee a op Popep7e | 2" PIS MI | ta rf??2" | srayag PY yo ia C974 2Fo\ ydo9d PL FPR) | rabay Te * prorated OD | Paalgng | syeop foansatao | | [— T | suonuaasayuy Butsunn, NVId dauVo ONISUNN i f