Week №1 1. General Family Information: • Full name of head of household: ____________ • Address: _______________________________ • Number of family members: _______________ • Age composition: children __ , adults __ , elderly __ • Language spoken in the family: ____________ • Contact phone number: ___________________ 2. Family Composition (Table) № Name Role Age Gender Education Occupatiion 1. Vasif Father 41 Male Doctor of Medicine Surgeon in hospital 3. Health Information of Family Member For each family member, indicate: • Full name • Age • Allergies (food, drug-related, seasonal): • Chronic diseases • Previous surgeries • History of infectious diseases • Disability status (if any) • Level of physical activity • Harmful habits (smoking, alcohol use etc) *Indicate the presence of the following condition among close relatives: cardiovascular diseases (hypertension, myocardial infarction, stroke), diabetes mellitus, oncological diseases, thyroid disorders, allergic diseases, mental disorders, autoimmune diseases. Specify who is affected and what age manifested. Week №2 1. Nutrition Assessment Checklist. 1. General information about the family. - Is there consistent access to food? - Who is responsible for the family’s meals? 2. Family diet. - What foods are consumed daily? - How often are the following included in the diet: meat, fish, eggs, dairy products, vegetables, fruits? - Are fruits and vegetables washed before consumption? - Main cooking methods: boiling, frying, baking, deep-frying? - How often are sweets, fast food, and carbonated drinks consumed? Is there a fast-food addiction? - Are there any restrictive diets in the family? - What kind of food do they prefer (spicy, with vinegar, without salt)? What foods are essential in the diet? 3. Child’s diet. - Breastfeeding / formula / mixed feeding (for infants) - When was solid food introduced (if applicable) - How many meals a day? - Is breakfast eaten daily? - Example of a daily diet: breakfast, lunch, dinner, snacks. - Are certain foods off-limits? - How often are sweets allowed? - Is food used as a reward or punishment? 4. Meal organization. - Who is involved in preparing meals in the family? - How often are home-cooked meals prepared? - How often are the following used: semi-prepared foods, ready-made store-bought meals, or delivery? If so, which ones and why? - Is the menu planned in advance? - Where do family members usually eat, and how often does the family eat together? 5. Eating habbits. - Do you eat while watching TV, using a phone or tablet, playing games, doing homework, or reading the newspaper? - Do you snack between meals? - Is eating done quickly or slowly? - Is there emotional eating (due to stress or boredom)? 6. Dietary supplements and nutrition. - Are dietary supplements (vitamins, minerals) used? - Are sports supplements or protein powders taken? - Are sugar substitutes or powdered mixes used? - Who prescribes the supplements (doctor / self-prescribed)? 7. Hydration and water. - Water source: Municipal water, well, bottled water, filtered water (what type of filter?) - Water usage: Do you drink tap water? Do you boil the water? - Hydration: How much water does the child drink per day? How much do adults drink? - What do you drink more often than water: tea, juices, sugary drinks, or water? 8. Economic and social factors. - Is there enough money for food? - Are there any restrictions on buying groceries? 9. Final assessment (for the student). - Is there a risk of malnutrition? - Is there a risk of overeating? - Are there any dietary irregularities? - Major hygiene issues? - What are your recommendations for the family? 2. Vaccination Assessment Checklist. Member Certificate? Missed vaccines? Additional note Dad Yes/no tuberculosis Allergy to components Mom Yes/no - Son Yes/no - Week №3 1. Family Sanitary and Hygienic Living Conditions Assessment Questionnaire 2. General Information. - Number of people living in the household: _____ - Type of housing: □ Apartment □ Private house □ Dormitory □ Other _________ - Are there any animals at home? ________________ 2. Housing Conditions. - How many living rooms are there in the home? ____ - Does the child have a separate sleeping place? □ Yes □ No 3. Lighting and Ventilation. - Is there sufficient natural lighting in the living rooms? □ Yes □ No - How often are the rooms ventilated? □ Several times a day □ Once a day □ Less frequently □ Rarely or never - Is cross-ventilation possible? □ Yes □ No - Is there a kitchen exhaust fan or ventilation system? □ Yes □ No - Are there any signs of dampness in the home? □ No □ Sometimes □ Yes If yes, please indicate: □ Damp walls □ Condensation on windows □ Musty odor □ Mold on walls or ceilings 4. Water Supply and Sanitation - Source of drinking water: □ Central water supply □ Public water standpipe □ Well / Borehole □ Bottled water □ Other __________ -Do you drink water without boiling or filtering it? □ Yes □ No - Is there continuous access to clean water? □ Yes □ No - Type of toilet facility: □ Indoor toilet □ Outdoor toilet - Is there a functioning sewage system? □ Yes □ No - Is there a handwashing area with soap available? □ Yes □ No 5. Kitchen Conditions. - Have you noticed any insects or pests in the home? □ No □ Ants □ Cockroaches □ Flies □ Mosquitoes □ Rodents □ Other __________ -Are there any signs of rodent activity? □ Yes □ No - Is household waste disposed of daily? □ Yes □ No 6. Smoking and Indoor Air Quality. - Does anyone smoke inside the home? □ No □ Occasionally □ Regularly - Are coal, wood, or other fuels used for heating inside the home? □ Yes □ No - Is there a noticeable smell of smoke, mold, or mustiness in the home? □ No □ Sometimes □ Frequently 7. Children’s Health. - How often has the child had acute respiratory infections during the past year? □ 0–2 times □ 3–5 times □ More than 5 times - Does the child experience any of the following? □ Persistent cough □ Wheezing □ Allergies □ Frequent runny nose □ Recurrent ear infections □ None of the above - Do these symptoms become worse while at home? □ No □ Yes □ Not sure 8. Final observations (for student). - Please mark any findings observed during the home visit: □ Visible mold □ Dampness □ Unpleasant odor □ Inadequate lighting □ Poor ventilation □ Insects □ Rodents □ Unsatisfactory kitchen sanitation □ Unsatisfactory sanitation of bathrooms and toilet facilities □ Overcrowded housing □ Lack of access to clean water □ Other ______________________________________ Conclusion: - Overall sanitary and hygienic condition of the household: □ Favorable □ Satisfactory □ Needs Improvement □ Unfavorable Comments:_____________________________________________________________________________________________________________________________________________________________________________ Week № 4 1. Questionnaire on Socio-Economic and Living Conditions. 1. General Information. - What is the main source of family income? - Are the parents employed? - Is the family income sufficient to cover basic needs? □ Yes □ Partially □ No - Has the family experienced financial difficulties over the past 12 months? □ Yes □ No 2. Social Support. - Are there relatives or other people who can help the family when needed? - Does the family receive any social support or benefits? - Does the family consider its social support sufficient? □ Yes □ Partially □ No 3. Child Development Conditions. - Does the child have a place for studying and doing homework? - Does the child attend kindergarten or school? - Does the child have opportunities for daily physical activity outdoors? 4. Home Safety. - Are there safety gates/railings on stairs and balconies? - Are medicines stored out of reach of children? - Are household chemicals stored out of reach of children? - Is there a functioning heating appliance in the home? 5. Psychosocial Environment. - How often do conflicts occur in the family? □ Never □ Sometimes □ Often - Is there anyone who helps the family in difficult situations? - Family relationships (supportive / conflict-prone / mixed): __________ - Level of stress in the family (low / moderate / high): __________ - Parental support and involvement (high / moderate / low): __________ 6. Digital Accessibility - Does the family have access to mobile phone service? - Does the family have access to the internet? 2. Questionnaire on Access to Healthcare. - Is the family registered with a family medicine center? - Do the children undergo preventive medical check-ups? - Do all family members have health insurance? - Do parents know where to seek medical help in an emergency? - Do parents have access to information about the child’s health (doctor, internet, parent education programs, etc.)? - How long does it take to reach the nearest medical facility? - Are there transportation difficulties when seeking medical care? - Can the family contact a healthcare worker by phone when needed? Week №5 1. KAP Questionnaire (Knowledge, Attitudes, Practices) Example: Knowledge 1.What are the main causes of diarrhea in children that you are aware of? 2.Do you know which vaccinations are included in the national immunization schedule? Attitudes 3.Do you think antibiotics should be taken only when prescribed by a physician? 4.Is it necessary to vaccinate a child who frequently becomes ill? Practices 5.Do you wash your hands with soap after using the toilet? 6.Do you take your child to a physician when body temperature exceeds 38°C? 2. Family Health Record (Sample Template) Name Age Health Status Vaccinations Nutrition Physical Activity Social Status Risks Aisha 6 years Healthy Unvaccinated No measlesFrequent sweets Active Kindergarten Low Grandfather 70 years Hypertension None Poor appetite Pensioner High BP Now you have to take an example and now keep South Indian names to that family and give answers accordingly to the given questions and make a medical survey report

Reading File

The report can be structured as a fictional, de-identified South Indian household case study, with plausible non-sensitive findings and clear student observations. It covers:

Asking for Preferences

Which section should I prepare in full first for the sample South Indian family medical survey report?

The report can be structured as a fictional, de-identified South Indian household case study, with plausible non-sensitive findings and clear student observations. It covers:I can prepare this as a fictional, de-identified South Indian family case study, using realistic but non-identifying details. It will cover:

Week 1: Family profile, composition, individual health history, and hereditary risks
Week 2: Nutrition assessment and vaccination status
Week 3: Sanitary, hygienic, housing, and child-health conditions
Week 4: Socioeconomic conditions, home safety, psychosocial setting, and access to healthcare
Week 5: KAP questionnaire and consolidated family health record

Suggested sample household: Mr. Aravind Kumar, a 41-year-old surgeon, living in Chennai with his wife Dr. Meenakshi Kumar, son Aditya, and mother Lakshmi. The report will state clearly that all details are hypothetical and intended only as an academic sample.

Which week would you like me to draft in full first?

Create the complete five-week medical survey report

Reading File

Finding Sources

Searching PubMed

family health AND nutrition

Searching the Web

WHO healthy diet fact sheet physical activity adults children immunization hygiene

Five-Week Family Medical Survey Report

Fictional academic sample only. All names, health details, and household information below are invented for educational use and are not real patient records.

Family Selected for Survey

Family name: Kumar Family
Location: Velachery, Chennai, Tamil Nadu
Language spoken at home: Tamil and English
Household type: Nuclear family with grandmother

Week 1: General Family and Health Assessment

1. General Family Information

Item	Details
Full name of head of household	Dr. Aravind Kumar
Address	Velachery, Chennai, Tamil Nadu
Contact phone number	+91-98XXXXXX42
Number of family members	5
Age composition	Children: 2; Adults: 2; Elderly: 1
Languages spoken	Tamil, English

2. Family Composition

No.	Name	Role	Age	Gender	Education	Occupation
1	Dr. Aravind Kumar	Father / head of household	41	Male	MBBS, MS General Surgery	Surgeon at a government hospital
2	Mrs. Meenakshi Kumar	Mother	38	Female	M.Sc., B.Ed.	Secondary-school science teacher
3	Aditya Kumar	Son	12	Male	Class VII	Student
4	Kavya Kumar	Daughter	6	Female	Class I	Student
5	Mrs. Lakshmi Kumar	Paternal grandmother	68	Female	Higher secondary education	Retired bank clerk

3. Individual Health Information

Family member	Age	Allergies	Chronic diseases	Previous surgeries	Infectious disease history	Disability status	Physical activity	Harmful habits
Dr. Aravind Kumar	41	No known food or drug allergies	Mild seasonal allergic rhinitis	Appendectomy at age 19	COVID-19 in 2021, recovered fully	None	Moderate. Walks 30 minutes, 4 days/week	No smoking. Occasional social alcohol use, 1-2 drinks/month
Mrs. Meenakshi Kumar	38	Allergy to diclofenac, causes rash	Hypothyroidism, controlled on prescribed treatment	Caesarean section twice	Chickenpox in childhood; COVID-19 in 2022	None	Light to moderate. Yoga 3 days/week, household activity	No tobacco or alcohol
Aditya Kumar	12	Dust allergy with occasional sneezing	Mild intermittent allergic rhinitis	None	Viral fever once in past year; no serious infectious illness	None	Active. Plays cricket and cycles 5-6 days/week	None
Kavya Kumar	6	No known allergies	None	None	Two uncomplicated upper respiratory infections in past year	None	Active. Outdoor play about 1 hour/day	None
Mrs. Lakshmi Kumar	68	No known drug allergy	Hypertension and osteoarthritis of both knees	Cataract surgery, age 65	COVID-19 in 2021, recovered	Mild mobility limitation due to knee pain; independent in daily activities	Light. Short walks and chair exercises	No tobacco or alcohol

4. Family History of Important Conditions

Condition	Affected relative	Age at onset / details
Hypertension	Mrs. Lakshmi Kumar	Diagnosed at approximately 58 years
Myocardial infarction	Aravind’s father, deceased	At 67 years
Stroke	No known family history	Not reported
Diabetes mellitus type 2	Meenakshi’s mother	Diagnosed at 54 years
Oncological disease	No known first-degree relative affected	Not reported
Thyroid disorder	Meenakshi Kumar	Hypothyroidism diagnosed at 34 years
Allergic diseases	Aravind and Aditya	Seasonal rhinitis since adolescence and childhood respectively
Mental disorders	No known family history	Not reported
Autoimmune diseases	No known family history	Not reported

Week 1 Student Assessment

The family has a generally favorable health profile. Important risks requiring preventive attention include:

Family history of hypertension, diabetes mellitus, and myocardial infarction.
Mrs. Lakshmi’s hypertension and reduced physical activity due to osteoarthritis.
Meenakshi’s hypothyroidism, which requires regular follow-up and adherence to prescribed treatment.
Allergy symptoms in Aravind and Aditya.
Aravind’s variable work schedule and occasional missed meals due to hospital duties.

Recommendations:

Annual blood pressure, blood glucose, lipid profile, and weight assessment for adults.
Regular review of thyroid function for Meenakshi as advised by her clinician.
Continued blood pressure monitoring and knee-pain management plan for Lakshmi.
Maintain regular physical activity and a balanced diet.
Avoid self-medication, especially antibiotics and pain medicines.
Keep allergy triggers, symptoms, and treatment advice documented.

Week 2: Nutrition and Vaccination Assessment

Part A: Nutrition Assessment Checklist

1. General Information

Question	Response
Is there consistent access to food?	Yes. The family has reliable access to food and groceries.
Who is responsible for meals?	Meenakshi plans the weekly menu. Lakshmi and Meenakshi usually prepare meals. Aravind helps on weekends.

2. Family Diet

Item	Survey finding
Foods eaten daily	Rice or millet-based dishes, dal/sambar, vegetables, curd, fruit, eggs or other protein foods
Meat consumption	Chicken or fish 2-3 times/week
Fish consumption	About once weekly
Eggs	4-5 days/week
Dairy products	Milk or curd consumed daily
Vegetables	At least two varieties most days
Fruits	Usually 1 serving/day, but not always for adults
Washing fruits and vegetables	Yes, under running water before preparation/consumption
Main cooking methods	Steaming, boiling, pressure cooking, sautéing, and baking. Deep-frying is uncommon
Sweets	1-2 times/week; more frequent during festivals
Fast food	About twice/month, usually pizza, dosa from outside, or fried snacks
Carbonated drinks	Rare, mainly during outings
Restrictive diets	Lakshmi follows a reduced-salt diet for hypertension. No other restrictive diet
Preferred food style	South Indian home-cooked food: idli, dosa, upma, rice, sambar, rasam, poriyal, curd rice, fish curry
Essential foods	Rice or millet, pulses, vegetables, curd, fruit, eggs, and fish/chicken

3. Children’s Diet

Aditya Kumar, 12 years

Item	Response
Meals per day	Three main meals and one evening snack
Breakfast daily	Usually yes. May occasionally skip during examination days
Sample daily diet	Breakfast: idli with sambar and milk. Lunch: rice, dal, vegetable poriyal, curd. Snack: fruit, sundal, or milk. Dinner: chapati or rice with vegetables and egg/fish curry
Foods avoided	No medical restriction. Dislikes bitter gourd
Sweets	Once or twice weekly
Food as reward or punishment	Parents try not to use food as a reward or punishment

Kavya Kumar, 6 years

Item	Response
Infant feeding history	Exclusively breastfed for approximately 6 months
Complementary foods introduced	At 6 months
Meals per day	Three meals and two healthy snacks
Breakfast daily	Yes
Sample daily diet	Breakfast: dosa/idli, milk, fruit. Lunch: school meal or home-packed rice, dal, vegetables, curd. Snack: banana, roasted chana, or milk. Dinner: chapati/rice with vegetable curry, dal, and egg twice weekly
Foods off-limits	Excess candy, packaged chips, and caffeinated soft drinks
Sweets allowed	Small portions once weekly or during special occasions
Food used for reward/punishment	No. Parents use verbal encouragement instead

4. Meal Organization

Question	Response
Who prepares meals?	Meenakshi and Lakshmi; Aravind assists on weekends
Frequency of home-cooked meals	6-7 days/week
Semi-prepared or delivery foods	Used about twice per month when both parents are busy
Common outside foods	Idli, dosa, vegetarian meals, occasional pizza or biryani
Is menu planned in advance?	Partly. Groceries and major meals are planned weekly
Usual place of eating	Dining table or kitchen dining area
Family meals together	Dinner together approximately 5 days/week

5. Eating Habits

Item	Finding
Screen use during meals	Children are not allowed screens during meals. Aravind occasionally checks his phone because of hospital calls
Snacking	Children take planned evening snacks. Adults sometimes snack on tea and biscuits
Speed of eating	Aditya tends to eat quickly; others eat at a moderate pace
Emotional eating	No regular emotional eating reported. Meenakshi may occasionally consume sweets during work-related stress

6. Supplements and Nutrition Products

Item	Response
Vitamins/minerals	Lakshmi takes vitamin D and calcium only when prescribed. Kavya takes a pediatric multivitamin intermittently on the pediatrician’s advice
Sports supplements/protein powders	None
Sugar substitutes/powdered mixes	No regular use
Who advises supplements?	Physician or pediatrician. Family avoids self-prescription

7. Hydration and Water

Question	Response
Water source	Municipal water passed through a household RO filter
Tap water consumed directly?	No
Water boiled?	Usually not after RO filtration; boiled water is used during episodes of gastrointestinal illness or when advised
Child water intake	Aditya approximately 1.5-2 L/day; Kavya approximately 1-1.2 L/day, adjusted for weather and activity
Adult water intake	Approximately 2-2.5 L/day for most adults, unless medically advised otherwise
Most frequent beverages	Water, milk, buttermilk, and tea. Sugary drinks are infrequent

8. Economic and Social Factors

Question	Response
Is family income enough for food?	Yes
Restrictions on buying groceries?	No significant restriction. The family sometimes limits expensive processed foods, not essential foods

9. Nutrition Assessment and Recommendations

Risk of malnutrition: Low.
Risk of overeating: Mild risk in adults due to occasional sedentary work and frequent rice-based portions.
Dietary irregularities: Aravind occasionally misses or delays meals. Aditya sometimes eats quickly. Fruit intake among adults can be improved.
Major hygiene concerns: None identified. Produce is washed, drinking water is filtered, and meals are mostly home prepared.

Nutrition recommendations:

Continue a varied diet containing vegetables, fruits, pulses, whole grains, nuts, dairy or alternatives, and protein-rich foods.
Increase fruit intake to at least 1-2 servings each day and ensure vegetables are included at lunch and dinner.
Reduce excess salt, pickles, papad, and processed foods, particularly due to Lakshmi’s hypertension and the family history of cardiovascular disease.
Encourage Aravind to carry a healthy snack during long hospital shifts.
Encourage Aditya to eat slowly and avoid distraction while eating.
Limit fried snacks, sugary beverages, and highly processed foods.
Continue regular outdoor activity and avoid using food as a reward or punishment.

These recommendations are consistent with WHO healthy-diet guidance, which supports varied diets with fruits, vegetables, legumes, whole grains, and lower intake of salt, free sugars, and unhealthy fats.

Part B: Vaccination Assessment

Note: This is a fictional documentation example. Vaccination records should always be verified against the local immunization card, school record, and the current national or state immunization schedule.

Member	Certificate / record available?	Missed vaccines?	Additional notes
Dr. Aravind Kumar	Yes	No known missed routine adult vaccines	Received COVID-19 primary vaccination and booster. Annual influenza vaccine recommended because of hospital exposure
Mrs. Meenakshi Kumar	Yes	No known missed vaccines	Receives vaccines according to physician advice; COVID-19 vaccination completed
Aditya Kumar	Yes	None identified from available record	Childhood vaccines documented. Adolescent booster status to be reviewed at the next clinic visit
Kavya Kumar	Yes	None identified from available record	Age-appropriate routine childhood vaccines documented
Mrs. Lakshmi Kumar	Partial record available	Influenza and pneumococcal vaccination status uncertain	Should discuss age-appropriate vaccines with her physician, especially due to age and hypertension

Vaccination assessment: The children appear to have received routine childhood vaccinations according to available records. Adult and elderly vaccination records should be reviewed annually, especially influenza, COVID-19, tetanus-containing boosters where indicated, and vaccines recommended for older adults.

Week 3: Family Sanitary and Hygienic Living Conditions Assessment

1. General Information

Item	Finding
Number of persons in household	5
Type of housing	Three-bedroom apartment
Animals at home	No pets

2. Housing Conditions

Question	Response
Number of living rooms	One living room, three bedrooms, kitchen, and two bathrooms
Does each child have a separate sleeping place?	Yes. Aditya and Kavya have separate beds in a shared bedroom

3. Lighting and Ventilation

Question	Response
Sufficient natural lighting	Yes, in all main living rooms
Frequency of ventilation	Several times a day
Cross-ventilation possible	Yes, in the living room and bedrooms
Kitchen exhaust/ventilation system	Yes, chimney/exhaust fan present
Dampness in home	Occasionally mild condensation near one bedroom window during monsoon
Damp walls	No
Condensation on windows	Sometimes
Musty odor	No
Mold on walls/ceilings	No visible mold

4. Water Supply and Sanitation

Question	Response
Source of drinking water	Central municipal supply with RO filtration
Drinks water without filtering/boiling	No
Continuous clean water access	Yes
Toilet facility	Indoor toilets
Functioning sewage system	Yes
Handwashing area with soap	Yes, available in kitchen and bathrooms

5. Kitchen Conditions

Question	Response
Insects or pests	Occasional ants during rainy season
Signs of rodent activity	No
Waste disposed of daily	Yes
Food storage	Dry foods stored in closed containers; cooked food refrigerated when not consumed immediately
Kitchen sanitation	Satisfactory. Countertops cleaned daily and utensils washed after meals

6. Smoking and Indoor Air Quality

Question	Response
Smoking inside the home	No
Coal, wood, or other solid fuels used indoors	No. LPG is used for cooking
Smell of smoke, mold, or mustiness	No

7. Children’s Health

Item	Aditya, 12 years	Kavya, 6 years
Acute respiratory infections during last year	1 episode	2 episodes
Persistent cough	No	No
Wheezing	No	No
Allergies	Occasional dust-related sneezing	No
Frequent runny nose	Occasionally during seasonal change	No
Recurrent ear infections	No	No
Symptoms worsen at home	No	No

8. Final Student Observations

Observation	Finding
Visible mold	No
Dampness	Mild occasional window condensation only
Unpleasant odor	No
Inadequate lighting	No
Poor ventilation	No
Insects	Occasional ants only
Rodents	No
Unsatisfactory kitchen sanitation	No
Unsatisfactory bathroom/toilet sanitation	No
Overcrowded housing	No
Lack of clean water	No
Other concern	Children share a room but have separate sleeping spaces and adequate storage

Conclusion

Overall sanitary and hygienic condition: Favorable

Comments: The household is clean, well ventilated, adequately lighted, and supplied with filtered drinking water. No indoor smoking or use of solid fuel is reported. The family should continue daily waste disposal, promptly manage seasonal ants, clean areas affected by condensation, and monitor for mold during the monsoon season.

Week 4: Socioeconomic, Living Conditions, and Access to Healthcare

Part A: Socioeconomic and Living Conditions Questionnaire

1. General Information

Question	Response
Main source of income	Salaries from Aravind’s hospital employment and Meenakshi’s teaching position; Lakshmi also receives a pension
Are parents employed?	Yes, both are employed
Is family income sufficient for basic needs?	Yes
Financial difficulties in previous 12 months?	No major difficulties reported

2. Social Support

Question	Response
Relatives or others available for help?	Yes. Maternal grandparents live nearby and can assist with childcare and emergencies
Does family receive social support/benefits?	Lakshmi receives her retirement pension; no regular additional social welfare support required
Is social support sufficient?	Yes

3. Child Development Conditions

Question	Response
Place for study/homework	Yes. Both children have a shared study desk, sufficient lighting, and school supplies
School attendance	Aditya attends Class VII; Kavya attends Class I
Daily outdoor activity	Yes. Aditya plays cricket and cycles; Kavya plays in the apartment complex or nearby park for approximately 1 hour/day

4. Home Safety

Question	Response
Safety gates/railings on stairs and balcony	Balcony has secure railing and safety mesh
Medicines out of reach of children	Yes. Stored in a locked cabinet
Household chemicals out of reach	Yes. Stored separately in a high locked utility cabinet
Functional heating appliance	Not usually required in Chennai. The home has safe electrical appliances for cooler weather
Emergency contacts available	Yes. Hospital, family physician, ambulance, and close relatives’ contacts are saved on phones

5. Psychosocial Environment

Item	Response
Frequency of family conflicts	Sometimes, usually related to schoolwork, screen time, or Aravind’s demanding work schedule
Help in difficult situations	Extended family, close friends, and workplace colleagues
Family relationships	Supportive overall
Stress level	Moderate, mainly due to work shifts and children’s school demands
Parental support and involvement	High

6. Digital Accessibility

Question	Response
Mobile phone access	Yes, all adults have mobile phones
Internet access	Yes, home broadband and mobile internet are available
Use of online health information	Used carefully. Aravind and Meenakshi prefer physician advice and trusted hospital or government sources

Part B: Access to Healthcare

Question	Response
Registered with family medicine center?	Yes, the family is registered with a nearby family medicine clinic
Do children receive preventive check-ups?	Yes, annual pediatric and dental reviews are generally completed
Do all members have health insurance?	Yes. Aravind has employer-supported coverage; other members are covered through family insurance
Do parents know where to seek emergency care?	Yes. Aravind’s hospital and a nearby multispecialty hospital are identified
Access to child-health information	Yes, through pediatrician visits, school information, trusted health websites, and parent education sessions
Time to nearest medical facility	Approximately 10-15 minutes by car or auto-rickshaw
Transportation barriers	No significant difficulties
Can they contact a healthcare worker by phone?	Yes, through clinic reception, hospital service, or emergency services

Week 4 Student Assessment

The family has favorable socioeconomic conditions, good social support, safe housing, adequate digital access, and appropriate access to healthcare. The main area requiring attention is stress management because both parents have demanding occupations.

Recommendations:

Maintain a regular family routine for meals, sleep, homework, and outdoor activity.
Schedule protected family time at least once weekly.
Continue safe storage of medicines and chemicals.
Limit children’s unsupervised screen time and promote age-appropriate digital safety.
Encourage Lakshmi to attend regular hypertension and mobility follow-up visits.
Ensure health insurance cards, vaccination records, prescriptions, and emergency contacts are kept in one accessible folder.

Week 5: KAP Questionnaire and Family Health Record

Part A: KAP Questionnaire

KAP = Knowledge, Attitudes, and Practices

Knowledge

Question	Family response	Student assessment
What are the main causes of diarrhea in children?	The parents identified contaminated food or water, poor hand hygiene, viral infection, and unsafe storage of cooked food	Good basic knowledge
Which vaccinations are included in the national immunization schedule?	Parents know about BCG, polio, DPT-containing vaccines, measles-rubella, hepatitis B, and other routine childhood vaccines, but would verify the current schedule at the clinic	Good awareness; exact schedule should be confirmed from official local records
What are warning signs of dehydration in children?	Reduced urination, lethargy, dry mouth, persistent vomiting, inability to drink, and sunken eyes	Good knowledge
Why is excessive salt intake a concern?	The family understands its association with high blood pressure, especially for Lakshmi	Good knowledge
Why should antibiotics not be taken for every fever or cold?	They understand that many colds are viral and antibiotics should be prescribed only after medical assessment	Appropriate knowledge

Attitudes

Question	Family response	Student assessment
Should antibiotics be taken only when prescribed by a physician?	Yes	Positive attitude
Is vaccination necessary even if a child frequently becomes ill?	Yes, unless a clinician identifies a specific temporary reason to defer it	Positive attitude
Is regular physical activity important for children and adults?	Yes. The family considers it important for fitness, mood, sleep, and prevention of chronic disease	Positive attitude
Is mental well-being as important as physical health?	Yes. Family members support discussing stress and seeking help when needed	Positive attitude
Should older adults receive regular health review even if they feel well?	Yes, because hypertension and other conditions can be asymptomatic	Positive attitude

Practices

Question	Family response	Student assessment
Do you wash hands with soap after using the toilet and before meals?	Yes	Appropriate practice
Do you take a child to a physician when temperature exceeds 38°C?	Usually yes if fever persists, the child appears unwell, has breathing difficulty, poor intake, rash, unusual sleepiness, or other warning signs	Appropriate, symptom-based practice
Do you avoid giving antibiotics without a prescription?	Yes	Appropriate practice
Do you filter drinking water?	Yes, household RO filter is used	Appropriate practice
Do children have daily physical activity?	Yes	Appropriate practice
Do family members smoke indoors?	No	Appropriate practice
Are medications kept safely?	Yes, in a locked cabinet	Appropriate practice

Part B: Family Health Record

Name	Age	Health status	Vaccinations	Nutrition	Physical activity	Social status	Risks
Dr. Aravind Kumar	41	Generally healthy; seasonal allergic rhinitis	Childhood record reported; COVID-19 vaccination completed; adult vaccine review advised	Mostly balanced diet, but irregular meal timing during shifts	Moderate. Walking 4 days/week	Employed surgeon; married	Family history of myocardial infarction and hypertension; work stress; occasional skipped meals
Mrs. Meenakshi Kumar	38	Hypothyroidism, clinically stable with prescribed care	Vaccination record available; COVID-19 vaccination completed	Balanced home diet; occasional stress-related sweets	Light-moderate. Yoga 3 days/week	Employed teacher; married	Family history of diabetes; thyroid disorder; stress from work and household duties
Aditya Kumar	12	Generally healthy; occasional allergic rhinitis	Routine childhood vaccines recorded	Generally balanced; occasional rapid eating and school-time breakfast delay	High. Cricket, cycling, outdoor play	School student	Family history of diabetes/cardiovascular disease; dust allergy
Kavya Kumar	6	Healthy	Routine childhood vaccines recorded	Balanced age-appropriate diet; limited sweets	High. Outdoor play daily	School student	Usual exposure to common childhood respiratory infections
Mrs. Lakshmi Kumar	68	Hypertension and bilateral knee osteoarthritis	Partial record available; adult vaccine status should be reviewed	Reduced-salt diet; appetite adequate	Light. Walking and chair exercises	Retired pensioner; lives with family	Hypertension, reduced mobility, fall risk, family history of cardiovascular disease

Overall Final Survey Conclusion

The Kumar family demonstrates favorable overall health, nutritional, sanitary, social, and healthcare-access conditions. The household has stable income, reliable food access, filtered water, a clean living environment, no indoor smoking, age-appropriate child care, and good access to medical services.

Main Identified Family Health Risks

Cardiovascular risk: Family history of hypertension, diabetes mellitus, and myocardial infarction.
Elderly health risk: Lakshmi has hypertension, knee osteoarthritis, and possible fall risk.
Lifestyle risk: Aravind’s irregular work schedule may lead to missed meals, stress, and reduced sleep.
Allergy risk: Aravind and Aditya experience seasonal or dust-related allergic rhinitis.
Moderate psychosocial stress: Both parents balance employment, childcare, and household responsibilities.
Minor home-environment concern: Occasional window condensation during monsoon should be monitored to prevent dampness or mold.

Consolidated Recommendations

Maintain annual preventive health examinations for all adults.
Monitor blood pressure regularly for Lakshmi and encourage medical review for knee pain, mobility, and fall prevention.
Screen adults periodically for diabetes and lipid abnormalities because of the family history.
Continue a low-salt, balanced diet with sufficient vegetables, fruits, pulses, whole grains, and protein sources.
Reduce fried snacks, excessive sweets, highly processed foods, and sugary drinks.
Ensure children continue daily outdoor play and healthy sleep routines.
Encourage Aravind to maintain regular meals, hydration, exercise, and adequate rest despite hospital shifts.
Review immunization records yearly, particularly adult and elderly vaccines.
Maintain safe food handling, filtered drinking water, daily waste disposal, and good hand hygiene.
Monitor condensation during rainy months and clean any damp areas promptly.
Maintain open family communication and use social support when stress increases.

A balanced diet and regular physical activity help lower long-term risk of cardiovascular disease, diabetes, and other noncommunicable diseases, as summarized in WHO healthy-diet guidance and WHO physical-activity recommendations.

Create a PDF checklist version for field visits

Reading File

Searching the Web

WHO household health survey home visit hygiene checklist guidance

Browsing Directory

Running Command

mkdir -p "/tmp/workspace/family-field-visit-checklist/src" "/tmp/workspace/family-field-visit-checklist/output" && printf '%s' 'ready'

Writing File

~/family-field-visit-checklist/src/create_checklist.py

from reportlab.lib import colors
from reportlab.lib.enums import TA_CENTER, TA_LEFT
from reportlab.lib.pagesizes import A4
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm
from reportlab.platypus import SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle, PageBreak, KeepTogether
from reportlab.pdfbase.pdfmetrics import stringWidth
from reportlab.pdfbase.ttfonts import TTFont
from reportlab.pdfbase import pdfmetrics
from reportlab.lib.colors import HexColor
from reportlab.pdfbase.pdfmetrics import registerFontFamily
from reportlab.pdfbase.ttfonts import TTFont
import os

OUT = '/tmp/workspace/family-field-visit-checklist/output/Five_Week_Family_Field_Visit_Checklist.pdf'
PAGE_W, PAGE_H = A4
BLUE = HexColor('#154C79')
TEAL = HexColor('#167C80')
LIGHT = HexColor('#EAF2F5')
MID = HexColor('#B7D4DA')
DARK = HexColor('#203040')
GREY = HexColor('#5E6A71')

styles = getSampleStyleSheet()
styles.add(ParagraphStyle(name='TitleCustom', parent=styles['Title'], fontName='Helvetica-Bold', fontSize=18, leading=22, textColor=BLUE, alignment=TA_CENTER, spaceAfter=8))
styles.add(ParagraphStyle(name='SubtitleCustom', parent=styles['Normal'], fontName='Helvetica', fontSize=9.2, leading=12, textColor=GREY, alignment=TA_CENTER, spaceAfter=12))
styles.add(ParagraphStyle(name='Week', parent=styles['Heading1'], fontName='Helvetica-Bold', fontSize=13, leading=16, textColor=colors.white, backColor=BLUE, borderPadding=(5,7,5,7), spaceBefore=6, spaceAfter=8))
styles.add(ParagraphStyle(name='Section', parent=styles['Heading2'], fontName='Helvetica-Bold', fontSize=10.5, leading=13, textColor=BLUE, spaceBefore=8, spaceAfter=4))
styles.add(ParagraphStyle(name='Small', parent=styles['Normal'], fontName='Helvetica', fontSize=8.2, leading=10.2, textColor=DARK))
styles.add(ParagraphStyle(name='Tiny', parent=styles['Normal'], fontName='Helvetica', fontSize=7.2, leading=8.5, textColor=DARK))
styles.add(ParagraphStyle(name='Note', parent=styles['Normal'], fontName='Helvetica-Oblique', fontSize=7.6, leading=9.4, textColor=GREY))


def P(text, style='Small'):
    return Paragraph(text, styles[style])

def field(label, width=0):
    return P(f'<b>{label}</b> ' + '_' * (width or 35), 'Small')

def section(title):
    return Paragraph(title, styles['Section'])

def checkbox(text):
    return P('□ ' + text, 'Small')

def grid(rows, widths, header=True, font=7.5):
    conv = []
    for r, row in enumerate(rows):
        conv.append([cell if hasattr(cell, 'wrap') else P(str(cell), 'Tiny' if font < 8 else 'Small') for cell in row])
    t = Table(conv, colWidths=widths, repeatRows=1 if header else 0, hAlign='LEFT')
    ts = [
        ('GRID',(0,0),(-1,-1),0.35,HexColor('#78909C')),
        ('VALIGN',(0,0),(-1,-1),'TOP'),
        ('LEFTPADDING',(0,0),(-1,-1),4),('RIGHTPADDING',(0,0),(-1,-1),4),
        ('TOPPADDING',(0,0),(-1,-1),4),('BOTTOMPADDING',(0,0),(-1,-1),4),
    ]
    if header:
        ts += [('BACKGROUND',(0,0),(-1,0),LIGHT),('TEXTCOLOR',(0,0),(-1,0),BLUE),('FONTNAME',(0,0),(-1,0),'Helvetica-Bold')]
    t.setStyle(TableStyle(ts))
    return t

def check_table(items, cols=2):
    cells = [checkbox(x) for x in items]
    rows = [cells[i:i+cols] for i in range(0,len(cells),cols)]
    if len(rows[-1]) < cols: rows[-1].append('')
    return Table(rows, colWidths=[8.45*cm/cols*2]*cols) if False else Table(rows, colWidths=[8.45*cm]*cols, hAlign='LEFT', style=[('VALIGN',(0,0),(-1,-1),'TOP'),('BOTTOMPADDING',(0,0),(-1,-1),3)])

def lines(n=2):
    return Spacer(1, 2), Table([[''] for _ in range(n)], colWidths=[17.2*cm], rowHeights=[0.5*cm]*n, style=[('LINEBELOW',(0,0),(-1,-1),0.35,colors.grey)])

def footer(canvas, doc):
    canvas.saveState()
    canvas.setFont('Helvetica', 7.5)
    canvas.setFillColor(GREY)
    canvas.drawString(1.5*cm, 1.0*cm, 'Family Field Visit Checklist | Academic use only - protect confidentiality')
    canvas.drawRightString(PAGE_W-1.5*cm, 1.0*cm, f'Page {doc.page}')
    canvas.restoreState()

doc = SimpleDocTemplate(OUT, pagesize=A4, rightMargin=1.5*cm, leftMargin=1.5*cm, topMargin=1.35*cm, bottomMargin=1.45*cm)
story=[]
story += [P('FIVE-WEEK FAMILY FIELD VISIT CHECKLIST', 'TitleCustom'), P('Printable medical, nutrition, hygiene, socioeconomic, and health-practice assessment form', 'SubtitleCustom')]
story += [P('<b>Use:</b> Record answers during a household visit. Obtain consent, avoid collecting unnecessary identifiers, and keep completed forms secure. This form supports screening and health education; it does not replace clinical diagnosis or emergency care.', 'Note'), Spacer(1,8)]
story += [grid([[field('Household / family ID:',18), field('Visit date:',14)], [field('Student / assessor:',18), field('Supervisor:',14)], [field('Locality / address:',18), field('Preferred language:',14)]], [10.8*cm,6.4*cm], header=False, font=8), Spacer(1,8)]
story += [section('Visit Log'), grid([['Week','Date','Completed','Follow-up / referral needed?'],['1. Family health','________________','□ Yes  □ No','□ Yes  □ No'],['2. Nutrition and vaccines','________________','□ Yes  □ No','□ Yes  □ No'],['3. Housing and hygiene','________________','□ Yes  □ No','□ Yes  □ No'],['4. Social conditions and healthcare','________________','□ Yes  □ No','□ Yes  □ No'],['5. KAP and health record','________________','□ Yes  □ No','□ Yes  □ No']], [3.7*cm,3.4*cm,4.0*cm,6.1*cm])]
story.append(PageBreak())

# WEEK 1
story += [P('WEEK 1 - FAMILY PROFILE AND HEALTH ASSESSMENT','Week')]
story += [section('1. General Family Information'), grid([[field('Head of household:',18),field('Contact number:',15)],[field('No. of members:',18),field('Languages spoken:',15)],[field('Children:',8)+'  '+field('Adults:',8),field('Older adults:',8)+'  '+field('Other:',8)]],[10.8*cm,6.4*cm],header=False)]
story += [section('2. Family Composition'), grid([['No.','Full name / initials','Relationship','Age','Sex','Education','Occupation'],['1','','','','','',''],['2','','','','','',''],['3','','','','','',''],['4','','','','','',''],['5','','','','','',''],['6','','','','','','']], [0.8*cm,3.4*cm,3*cm,1*cm,1*cm,3.8*cm,4.2*cm])]
story += [section('3. Individual Health Information'), P('Complete one row per person. Use a separate continuation sheet if necessary.','Note'), grid([['Name / age','Allergies','Chronic conditions','Past surgery / infectious illness','Disability / activity level','Tobacco, alcohol, other risks'],['','','','','',''],['','','','','',''],['','','','','',''],['','','','','',''],['','','','','','']], [2.3*cm,2.5*cm,3*cm,3.5*cm,3.1*cm,2.8*cm])]
story += [section('4. Family History in Close Relatives'), grid([['Condition','Present?','Who is affected / age at onset / comments'],['Hypertension, heart attack, stroke','□ Yes □ No',''],['Diabetes mellitus','□ Yes □ No',''],['Cancer','□ Yes □ No',''],['Thyroid disorder','□ Yes □ No',''],['Allergy / asthma','□ Yes □ No',''],['Mental health condition','□ Yes □ No',''],['Autoimmune disease','□ Yes □ No','']], [5.5*cm,3*cm,8.7*cm])]
story += [section('Week 1 Assessment and Plan'), P('<b>Priority health concerns:</b> _________________________________________________________________________________________________', 'Small'), Spacer(1,7), P('<b>Advice / follow-up / referral:</b> __________________________________________________________________________________________________', 'Small'), Spacer(1,7), P('<b>Assessor signature:</b> ____________________________  <b>Date:</b> ____________________', 'Small')]
story.append(PageBreak())

# WEEK 2
story += [P('WEEK 2 - NUTRITION AND VACCINATION ASSESSMENT','Week')]
story += [section('1. Family Nutrition and Food Access'), grid([['Question','Response / notes'],['Consistent access to adequate food? Who plans / prepares meals?',''],['Foods eaten daily',''],['Frequency: meat, fish, eggs, dairy, vegetables, fruits',''],['Are fruit and vegetables washed before use?',''],['Main cooking methods',''],['Frequency of sweets, fast food, carbonated drinks',''],['Restrictive diets, food preferences, essential foods','']], [7.6*cm,9.6*cm])]
story += [section('2. Child Nutrition - Complete for Each Child'), grid([['Item','Child 1: name / age','Child 2: name / age'],['Infant feeding / age solids introduced, if relevant','',''],['Meals/day and daily breakfast','',''],['Usual breakfast, lunch, dinner, snacks','',''],['Foods avoided / allergies / restrictions','',''],['Sweets frequency; food as reward or punishment?','','']], [4.7*cm,6.25*cm,6.25*cm])]
story += [section('3. Meal Organization and Eating Habits'), check_table(['Home-cooked meals most days','Menu planned in advance','Family eats together regularly','Screens used during meals','Frequent snacking between meals','Eating is usually rushed','Emotional eating reported','Semi-prepared / delivery meals used frequently'],2)]
story += [section('4. Supplements, Hydration, and Economic Factors'), grid([['Item','Response / notes'],['Vitamins, minerals, protein powders, sugar substitutes. Who advised them?',''],['Drinking-water source and treatment: municipal / borehole / bottled / filtered / boiled',''],['Approximate daily fluid intake: children / adults',''],['Usual beverages besides water',''],['Enough money for food? Grocery-purchasing restrictions?','']], [7.6*cm,9.6*cm])]
story += [section('5. Vaccination Assessment'), grid([['Member','Certificate / record?','Missed / uncertain vaccines','Allergy / other note'],['Father / adult 1','□ Yes □ No','',''],['Mother / adult 2','□ Yes □ No','',''],['Child 1','□ Yes □ No','',''],['Child 2','□ Yes □ No','',''],['Older adult / other','□ Yes □ No','','']], [3.1*cm,3.4*cm,5.3*cm,5.4*cm])]
story += [section('Week 2 Final Assessment'), check_table(['Risk of undernutrition','Risk of overeating','Irregular meal pattern','Food hygiene concern','Unsafe water concern','Vaccination record needs review'],2), P('<b>Recommendations / referral:</b> ________________________________________________________________________________________________', 'Small')]
story.append(PageBreak())

# WEEK 3
story += [P('WEEK 3 - SANITARY, HYGIENIC, AND HOUSING CONDITIONS','Week')]
story += [section('1. Home and Housing'), grid([['Item','Finding'],['Number living in household',''],['Housing type','□ Apartment  □ Private house  □ Dormitory  □ Other: __________'],['Animals / pets at home',''],['No. of living rooms',''],['Child has separate sleeping place','□ Yes  □ No  □ Not applicable']], [7.2*cm,10*cm])]
story += [section('2. Lighting, Ventilation, and Dampness'), check_table(['Adequate natural light','Rooms ventilated several times/day','Cross-ventilation possible','Kitchen exhaust / ventilation present','Damp walls present','Window condensation present','Musty odour present','Visible mold on walls/ceilings'],2)]
story += [section('3. Water, Sanitation, and Kitchen'), grid([['Item','Finding'],['Drinking-water source','□ Central supply  □ Public standpipe  □ Well/borehole  □ Bottled  □ Other'],['Water used without boiling/filtering','□ Yes  □ No'],['Continuous access to clean water','□ Yes  □ No'],['Toilet','□ Indoor  □ Outdoor'],['Functioning sewage system','□ Yes  □ No'],['Handwashing point with soap','□ Yes  □ No'],['Pests observed','□ None  □ Ants  □ Cockroaches  □ Flies  □ Mosquitoes  □ Rodents  □ Other'],['Rodent activity / food storage / daily waste disposal','']], [7.2*cm,10*cm])]
story += [section('4. Indoor Air Quality and Children’s Health'), grid([['Item','Finding'],['Anyone smokes indoors?','□ No  □ Occasionally  □ Regularly'],['Coal, wood, or other solid fuel used indoors?','□ Yes  □ No'],['Smoke, mold, or musty odor','□ No  □ Sometimes  □ Frequently'],['Child respiratory infections over past year','□ 0-2  □ 3-5  □ More than 5'],['Child symptoms','□ Persistent cough □ Wheeze □ Allergy □ Runny nose □ Ear infections □ None'],['Symptoms worse while at home?','□ No  □ Yes  □ Not sure']], [7.2*cm,10*cm])]
story += [section('5. Final Observations'), check_table(['Visible mold/dampness','Unpleasant odor','Inadequate lighting','Poor ventilation','Insects or rodents','Unsatisfactory kitchen sanitation','Unsatisfactory bathroom/toilet sanitation','Overcrowding','No access to clean water','Other concern'],2), P('<b>Overall condition:</b> □ Favorable  □ Satisfactory  □ Needs improvement  □ Unfavorable', 'Small'), Spacer(1,5), P('<b>Comments and recommended action:</b> ____________________________________________________________________________________', 'Small')]
story.append(PageBreak())

# WEEK 4
story += [P('WEEK 4 - SOCIOECONOMIC CONDITIONS AND ACCESS TO HEALTHCARE','Week')]
story += [section('1. Income and Social Support'), grid([['Question','Response / notes'],['Main household income source; parent employment',''],['Income sufficient for basic needs?','□ Yes  □ Partly  □ No'],['Financial difficulty during past 12 months?','□ Yes  □ No'],['Relatives / community support available?',''],['Social support / benefits received',''],['Is social support sufficient?','□ Yes  □ Partly  □ No']], [8.2*cm,9*cm])]
story += [section('2. Child Development, Home Safety, and Psychosocial Environment'), grid([['Item','Finding'],['Space for study/homework','□ Yes  □ No'],['School / kindergarten attendance','□ Yes  □ No  Notes: __________________'],['Daily outdoor physical activity opportunity','□ Yes  □ No'],['Safe railings / balcony / stairs where applicable','□ Yes  □ No  □ N/A'],['Medicines stored out of children’s reach','□ Yes  □ No'],['Household chemicals stored out of children’s reach','□ Yes  □ No'],['Heating/cooking appliances functioning and safely used','□ Yes  □ No'],['Family conflicts','□ Never  □ Sometimes  □ Often'],['Family relationships','□ Supportive  □ Mixed  □ Conflict-prone'],['Stress level','□ Low  □ Moderate  □ High'],['Parental support/involvement','□ High  □ Moderate  □ Low']], [8.2*cm,9*cm])]
story += [section('3. Digital Access and Healthcare Access'), grid([['Item','Finding'],['Mobile phone service / internet access','□ Phone  □ Internet  □ Both  □ Neither'],['Registered with family medicine center / clinic?','□ Yes  □ No'],['Children receive preventive check-ups?','□ Yes  □ No'],['All members have insurance / coverage?','□ Yes  □ No  □ Not sure'],['Parents know where to seek emergency care?','□ Yes  □ No'],['Access to trusted child-health information','□ Clinician □ Internet □ Parent program □ Other'],['Travel time to nearest facility','________________ minutes'],['Transport difficulty seeking care?','□ No  □ Yes: __________________'],['Can contact healthcare worker by phone?','□ Yes  □ No']], [8.2*cm,9*cm])]
story += [section('Week 4 Assessment and Plan'), P('<b>Social / safety / access barriers identified:</b> _______________________________________________________________________________', 'Small'), Spacer(1,7), P('<b>Support, education, or referral arranged:</b> __________________________________________________________________________________', 'Small')]
story.append(PageBreak())

# WEEK 5
story += [P('WEEK 5 - KAP QUESTIONNAIRE AND FAMILY HEALTH RECORD','Week')]
story += [section('1. Knowledge, Attitudes, and Practices (KAP)')]
story += [grid([['Domain','Question','Response / assessor notes'],['Knowledge','Main causes of diarrhea in children?',''],['Knowledge','Which routine childhood vaccinations are known?',''],['Knowledge','Warning signs requiring medical review for fever, breathing difficulty, or dehydration?',''],['Attitude','Antibiotics should be used only if prescribed by a clinician.','□ Agree  □ Unsure  □ Disagree'],['Attitude','A frequently ill child should still receive vaccines unless a clinician advises delay.','□ Agree  □ Unsure  □ Disagree'],['Practice','Handwashing with soap after toilet use and before food preparation/eating.','□ Always  □ Sometimes  □ Rarely'],['Practice','When does the family seek care for a child with fever?',''],['Practice','Use of unprescribed antibiotics / other medicines?','□ No  □ Yes: __________________']], [2.2*cm,7.3*cm,7.7*cm])]
story += [section('2. Family Health Record'), grid([['Name / initials','Age','Health status','Vaccinations','Nutrition','Activity','Social status','Key risks'],['','','','','','','',''],['','','','','','','',''],['','','','','','','',''],['','','','','','','',''],['','','','','','','','']], [2.3*cm,0.9*cm,2.7*cm,2.4*cm,2.5*cm,1.8*cm,2.4*cm,2.2*cm])]
story += [section('3. Final Household Summary'), grid([['Area','Assessment'],['General health status','□ Favorable  □ Needs follow-up  □ Concern identified'],['Nutrition','□ Adequate  □ Needs counseling  □ Concern identified'],['Vaccination record','□ Current / verified  □ Needs review  □ Incomplete'],['Hygiene and environment','□ Favorable  □ Needs improvement  □ Urgent concern'],['Socioeconomic / healthcare access','□ Adequate  □ Barrier identified  □ Referral needed']], [7.2*cm,10*cm])]
story += [section('Priority Action Plan'), P('1. _________________________________________________________________________________________________________________', 'Small'), Spacer(1,8), P('2. _________________________________________________________________________________________________________________', 'Small'), Spacer(1,8), P('3. _________________________________________________________________________________________________________________', 'Small'), Spacer(1,10), P('<b>Assessor name/signature:</b> _________________________________  <b>Date:</b> _________________________________', 'Small'), Spacer(1,6), P('<b>Supervisor comments:</b> ______________________________________________________________________________________________', 'Small')]
story += [Spacer(1,10), P('Safety note: Refer promptly according to local protocol if there is severe acute illness, danger signs in a child, suspected abuse or violence, lack of safe water, unsafe housing, or inability to access urgent medical care.', 'Note')]

doc.build(story, onFirstPage=footer, onLaterPages=footer)
print(OUT)

Running Command

python "/tmp/workspace/family-field-visit-checklist/src/create_checklist.py" && ls -lh "/tmp/workspace/family-field-visit-checklist/output/Five_Week_Family_Field_Visit_Checklist.pdf"

Reading File

Editing File

~/family-field-visit-checklist/src/create_checklist.py

Successfully replaced 1 instance(s) of the string in '/tmp/workspace/family-field-visit-checklist/src/create_checklist.py'

Running Command

python "/tmp/workspace/family-field-visit-checklist/src/create_checklist.py" && ls -lh "/tmp/workspace/family-field-visit-checklist/output/Five_Week_Family_Field_Visit_Checklist.pdf"

Running Command

python -c "from pypdf import PdfReader; p='/tmp/workspace/family-field-visit-checklist/output/Five_Week_Family_Field_Visit_Checklist.pdf'; r=PdfReader(p); print('pages=',len(r.pages)); print('page1=',r.pages[0].extract_text()[:450].replace('\\n',' | ')); print('last=',r.pages[-1].extract_text()[-450:].replace('\\n',' | '))"

Created a printable 7-page PDF checklist for all five field-visit weeks. It includes family profile, medical history, nutrition and vaccination review, household hygiene, socioeconomic and healthcare access assessment, KAP questions, family health record, and final action plan.

Five Week Family Field Visit Checklist

PDF Document · PDF

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