Name: _________________________________________________

Age: __________ years

Gender: F Others

Contact number

Neighbourhood

Closest landmark

No. of family members

Language

Kannada Hindi Tamil Telugu Other _______________________

No. of years in Bangalore:

Migrant (Y/N)

If < 16, do you attend school? Y N

Do you get a mid-day meal in school?

If > 18, employment (Full-time, part-time, contract, daily-wage, unemployed, other)

Family income level

< 10000 10000 – 25000 25000 – 60000 60000 – 120000 120000 – 200000 200000 – 300000 >300000

Type of house

No house Tarpaulin Thatched house Sheet roof

Pukka house Others _______________________

Access to toilet

Yes No

No. of meals per day

1 2 3 4+ None

Known medical problems

Diabetes High BP Low BP High blood sugar Low blood sugar Anaemia Others _______________________________

Remarks / Additional notes

Eg: Single parent, physically challenged, mental illness, terminal illness, geriatric, etc.