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.
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