Health Camp Survey | Minal Yuva Sangathan

Rural Sick Patient Identification & Health Camp Survey

Minal Yuva Sangathan

Purpose: This survey is conducted by Minal Yuva Sangathan to identify ill and needy rural residents and to organize free health camps, medical check-ups, and treatment support through the organization.

A. Location Details

Village

Block / Tehsil

District

State

Survey Date

B. Volunteer Details

Volunteer Name

Volunteer ID

Signature (Type Name)

C. Patient Basic Details

Patient Name

Age (Years)

Gender

Mobile Number

Aadhaar (Last 4 digits, if available)

D. Family & Economic Status

Total Family Members

Monthly Family Income

Occupation

E. Health Condition Details

Current Illness / Problem (Tick applicable):

Fever Diabetes Blood Pressure Heart Disease Asthma TB Joint Pain Women Health Issue Child Illness

Other Illness

Duration of Illness

Is the patient under any treatment currently?

Yes No

Hospitalization in last 1 year:

Yes No

F. Health Insurance & Support

Any Health Insurance / Government Scheme?

Ayushman Bharat (PM-JAY) State Health Scheme Private Insurance No Insurance

Does the patient need free medical assistance?

Yes No

G. Health Camp Requirement

Type of Support Required:

General Health Check-up Doctor Consultation Free Medicines Diagnostic Tests Referral to Hospital

Preferred Health Camp Location (if any)

Patient / Guardian Signature / Thumb Impression (Type Name)

Rural Sick Patient Identification & Health Camp Survey

Volunteer Verification Required

A. Location Details

B. Volunteer Details

C. Patient Basic Details

D. Family & Economic Status

E. Health Condition Details

F. Health Insurance & Support

G. Health Camp Requirement

H. Consent & Declaration