SOCIO-ECONOMIC STUDY

1. GENERAL USER DATA

Name: ____________________________________ Sex: ___________ Age: ______

Paternal Surname, Maternal Surname, First Name

Date of Birth: _____________ Place and Origin: _____________________

Day month Year

Marital status_____________Education: _________________ Occupation_______________

Last degree completed

Type of Disability: __________________________________

2. HOUSEHOLD IDENTIFICATION DATA

Home: __________________________________________________________________
Street No. Cologne

__________________________________________________________________________________
CP Territorial Unit Delegation

Streets adjacent to the address: ______________________________________________________

Telephone: ________________ Means of transportation to get to the home:______________

4.- FAMILY INCOME AND EXPENSES

Monthly INCOME (record who, how much they contribute and total amount.).
Monthly EXPENDITURE
Types of Expenses Amount Expense type

Feeding $___________ Transport $__________

Gas Or Fuel $___________ Education $__________
Rent $___________ Medical expenses $__________
Water $___________ Recreation $__________
Predial $___________ Subscriptions or credits $__________
Electricity (Light) $___________ Clothes and shoes $__________
Phone $___________ savings funds, $__________
Cell phone $___________ batches, loans
Home construction credit $__________
$__________

Surplus
Total Expenditures $__________ Deficit $__________
$__________

5. HOUSING

Housing tenure
Own ( ) Rented ( ) Borrowed ( ) Invaded ( )
Housing type
Single house ( ) Apartment ( ) Neighborhood ( ) Camp ( ) Hostel ( ) Accessory ( )
Number of bedrooms: ________ Overcrowding index: ________ Living room ( ) Dining room ( )
Kitchen ( ) Private bathroom ( ) Collective bathroom ( )
Predominant material in housing construction
Walls: Partition ( ) Wood ( ) Cardboard ( ) Other materials ( ) Specify: ___________
Roofs: Concrete ( ) Asbestos sheet ( ) Cardboard sheet ( ) Metal sheet ( )
Floors: Mosaics ( ) Tile ( ) Cement ( ) Rammed earth ( ) Wood ( )
Other material: (specify) _________________
Furniture:
Television ( ) Stereo ( ) Video ( ) DVD ( ) Stove ( ) Microwave oven ( )
Washing machine ( ) Laundry center ( ) Refrigerator ( ) Computer ( )
 6. HEALTH

Medical services that the family has:

IMSS ( ) ISSSTE ( ) Health Center ( ) Dispensary ( ) Private Doctor ( ) Others ( ) (Specify)
________________
Frequency with which the user visits the doctor:
Once a week ( ) Monthly ( ) Yearly ( ) When you get sick ( )
Frequent illnesses in the family:
Respiratory ( ) Which is it)? __________ Who suffers from it? ___________
Gastrointestinal ( ) Which is it)? __________ Who suffers from it? ___________
Dermatological ( ) Which is it)? __________ Who suffers from it? ___________
Neurological ( ) Which is it)? __________ Who suffers from it? ___________
Cancer ( ) What type? __________ Who suffers from it? ___________
Hypertension ( ) Which is it)? __________ Who suffers from it? ___________
Obesity ( ) Which is it)? __________ Who suffers from it? ___________
Mellitus diabetes ( ) What type? __________ Who suffers from it? ___________

7.- FOOD

Type of food Frequency with which you consume it

Diary Every third Once a week Once Occasionally
day a month
Beef
Chicken meat
Pork Meat
Fish meat
Milk
Cereals
Egg
Fruit
Vegetables
Legumes
Beans, broad
beans, lentils,
Beans, alverjón,
etc.

8.- RECREATION AND USE OF FAMILY FREE TIME

Family activities on the weekend:

Play sports ( ) Go to the movies ( ) Visit relatives ( ) Do household chores ( )
Outdoor activities ( ) Other: __________________________________
Specify
User activities: study (if yes, what do you study)___________________
Do sports ( ) Watch television ( ) Do your homework ( )
Do housework ( )
Video games ( ) Play with friends ( ) Play with brother or family ( ) Work ( )
Others (specify)_______________________________________________________

9.- FAMILY DYNAMICS:

A) Organization and operation

_______________________________________________________________
_______________________________________________________________
B) Communication
_______________________________________________________________
_______________________________________________________________
C) Roles
_______________________________________________________________
_______________________________________________________________
D) Authority
_______________________________________________________________
_______________________________________________________________
E) Limits
_______________________________________________________________
_______________________________________________________________
F) Expression of affection
_______________________________________________________________
_______________________________________________________________
G) Life Cycle
_______________________________________________________________
_______________________________________________________________

10.- FAMILIOGRAM
11.- SOCIAL DIAGNOSIS
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

12.- OBSERVATIONS OF THE SOCIAL WORK STUDENT

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Application Date

Day Mont Year

h

Student Social Worker Teacher Supervisor

____________________
Name and signature
Name and signature
. FAMILIAR STRUCTURE
(People who live in the home )

No. Full name Age Sex Civil Relationship Scholarship Go to Occupation Health Observations
status with the user school condition