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APPENDIX I
INDIAN COUNCIL OF MEDICAL RESEARCH
CENTRE FOR ADVANCED RESEARCH ON 'HEALTH AND BEHAVIOUR'
Government Rajaji Hospital and Madurai Medical College, Madurai 20
'HEALTH CARE OF THE RURAL AGED-A TASK FORCE PROJECT'
STUDY PROFORMA
SECTION I
SOCIO DEMOGRAPHIC AND PSYCHOSOCIAL DATA
         
Personal Particulars :        
Name : Age : Sex : Date :  
Address :        
(1-3) Job Number      
(4-5) Card Design      
(6-7) Card Number      
(8-9) Sub-centre      
(10-11) Village      
(12-14) Serial No.      
(15-19) Kallandiri PHC OP No.      
(20) Followup      

Key

       
- Initial
- 6 month followup
- 1 year followup
- 1½ years followup
- 2 years followup
- 2½ years followup
1
2
3
4
5
6
     
(21) Age      
Key
       
- 60-64
- 65-69
- 70-74
- 74 and above
1
2
3
4
     
(22) Sex      
Key
       
- Male
- Female
1
2
     
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