FAMILY
FOLDER
Date of registration: Folder No:
Head of the family:
House No:
House:
Own/ Rented
Address:
Type of house: Pucca/Semi pacca/kaccha
Religion: No of rooms:
Caste :
Ventilation:
well/ ill
Type of family:
Nuclear/Joint/Extended Total monthly
income.................Rs.
No of Family members: Food
pattern: Veg./Non veg.
Family care group members:
New
born/Infant/ under five /School age children /Adolescent
/Antenatal mother /Postnatal mother /Geriatric person
If
morbidity is present specify:
FAMILY
CHARACTERISTICS
S.N
|
Name of the family members
|
Relation-ship with head of the family
|
Sex
|
Age
|
Educatio-nal status
|
Occu…/income
|
Marital status
|
Nutritional status
|
Health status
|
Remarks
|
Environmental Condition:
Electricity facility : Yes/No
Drainage:
Water supply :
Tap water/Dug well/Bore well/Lake/River
Latrine: Yes/No
Disposal of waste : Hygienic /Unhygienic
Presence of
Rodents & Pests: If specify…………………
Animals Kept: Yes/No If Yes Specify…………. .Pet animals: Yes/No If Yes Specify………….
HEALTH VISIT RECORD
S.no.
|
Date of visit
|
Name
|
Needs
|
Problems
|
Treatment details
Hospital/home
|
Referral service if needed, follow up
|
Health education
|
Sign.
|
HEALTH VISIT RECORD
S.no.
|
Date of visit
|
Name
|
Needs
|
Problems
|
Treatment details
Hospital/home
|
Referral service if needed, follow up
|
Health education
|
Sign.
|
INFANT
/UNDER FIVE RECORD
F.F.NO: Date:
Date: ………………….
1.Name………………………….2.Age………yrs………m; 3.Sex;M/F…………..4.
Birth order………………
5. Natal history:
a. Date of birth:…………………,
b) Term /Preterm/Post term c) Place:
Hospital/Home/Others………
d) Type of
delivery: Vginal/Instumental/Caesarean
e) Conducted by:
HW/Doctor/TBA/Dai/OTHERS………..
f) Labour progress: Normal/Prolonged
Labour/Preterm labour
6. Neonatal History:
a) Admission in
nursery: Y/N b) Umbilical Sepsis:
Y/N c) Umbilical cord shed off
in……Days
d) Muconium passed
on………….Day e) Feeding
problem’s/N f) Hyper/Hypothermia’s:
Y/N
g) Congenital
malformation’s: Y/N if yes
specify…………………………………
7. Diet History:
(I)Breast
feeding:
(II) Weaning:
a. Initiation
time:
a. Started/Not started:
b. Colostrums given: Y/N b.
Expected age of weaning if less than 6 months:
c. Any top
feed/Milk/water given: Y/N c.
Actual age of weaning if more than 6 months:
d. Exclusive:
Y/N: d.
Weaning food: ………………………………………………
e. Duration of
EBF:
e. any problems……………………………………………….
f. Demand feeding:
Y/N
8. Immunization details: I-Card;
Present/Absent
Vaccines
|
Date
|
Vaccines
|
Date
|
Vaccines
|
Date
|
Vaccines
|
Date
|
BCG.
|
DPT-2
|
Hep.B-3
|
DPT Booster-2
|
||||
OPV-0
|
OPV-2
|
Measles
|
DT-Booster
|
||||
DPT-1
|
Hep.B-2
|
Vit.-A
|
OPV Booster
|
||||
OPV-1
|
DPT-3
|
DPT Booster-1
|
|||||
Hep.B-1
|
OPV-3
|
OPV Booster
|
9. Primary immunization
status of the children 12-23 months of age: complete/incomplete/nothing given
till date
10. If not
completely immunized what is the reason………………………………………………….
11. Number of
Vitamin A doses given till age 5years: …………………………
12. Any other
Vaccine given: Y/N If Yes What: ……………………………………….
13.Anthropometry assessment:
Particulars
|
Visits
|
|||||
1st
|
2nd
|
3rd
|
4th
|
5th
|
6th
|
|
Date
|
||||||
Height/length
|
||||||
Weight
|
||||||
Head
circumference
|
||||||
Chest
circumference
|
||||||
MUAC
|
||||||
14. General Examination:
Head to foot assessment
|
Visits
|
||||
1st/DATE:
|
2nd/DATE:
|
3rd/DATE:
|
4th/DATE:
|
5th/ DATE:
|
|
Skin
|
|||||
Head
|
|||||
Eyes
|
|||||
Nose
|
|||||
Mouth
|
|||||
Ears
|
|||||
Neck
|
|||||
Chest
|
|||||
Abdomen
|
|||||
Back
|
|||||
Extremities
|
|||||
Genitalia
|
|||||
15. Nutritional status:
Nourishment/Under Nourishment/ Over
Nourishment
Degree of malnutrition: 1st
degree/2nd degree/ 3rd degree
16. Developmental details
Skills
|
Visits
|
||||
1st
|
2nd
|
3rd
|
4th
|
5th
|
|
Gross motor skills
|
A/NA
|
A/NA
|
A/NA
|
A/NA
|
A/NA
|
Fine motor/Adaptive skills
|
A/NA
|
A/NA
|
A/NA
|
A/NA
|
A/NA
|
Personal/social skills
|
A/NA
|
A/NA
|
A/NA
|
A/NA
|
A/NA
|
Language skills
|
A/NA
|
A/NA
|
A/NA
|
A/NA
|
A/NA
|
A=Achieved; NA=Not Achieved
Gross motor skills
|
Fine motor/Adaptive skills
|
Personal/Social skills
|
Language Skills
|
•
Neck steadiness(4m)
•
Turning over(5m)
•
Sit with support(6m)
•
Creeping (7m)
•
Sit without support(9m)
•
Crawling(9m)
•
Stand with Support(10m)
•
Stand with out Support (11m)
•
Walk with support(12m)
•
Walk with out support(16m)
•
Play activities according to the
age
|
•
Eye fixation(1.5m)
•
Mouthing(5m)
•
Single hand approach(7m)
•
Pincer grasp(9m)
•
Stop mouthing (12m)
|
•
Social smile(3m)
•
Anxiety to strangers(4m)
•
Dry by day(15m)
•
Dry by night(2-2.5 yrs)
•
Playing with children(3yrs)
|
•
Alerts to sounds (2m)
•
Monosyllables(mama)(10m)
•
3 meaning full words(1 yr)
•
Few sentences(2yr)
|
SIGNATURE:
ANTENATAL RECORD F.F.NO: Date:
•
Name:
•
Age:
|
•
Age
at menarche:
•
Duration
of menstrual cycle:
•
Age
at the time of the marriage:
|
•
Duration
of cohabitation
|
•
Age
at conception of first child:
|
•
Any
contraceptive use before present pregnancy :Yes/No
-If
No, reason for not using…………………….
-If
Yes, Type…………………………
Period
of use:…………………….
Any
problems due to it…………
|
•
Past
history of: polio/diabetes/hypertension/rheumatic
fever/jaundice/ surgery/rickets/TB/ any other significant illness
|
•
G-P-A-L-D
|
•
Details of previous delivery
|
Pregnancies
in chronological order
|
||||
1st
|
2nd
|
3rd
|
4th
|
5th
|
|
•
When was pregnancy registration
done
|
|||||
•
Spacing duration
|
|||||
•
No. of antenatal visit
|
|||||
•
Tetanus toxoid doses: 0/1/2
|
|||||
•
IFA tablet consumed: Y/N
|
|||||
•
Place of delivery:
home/institutional
|
|||||
•
Conducted by whom:
doctors/nurses//health workers/Dai/TDA/relatives
/others
|
|||||
•
Nature of delivery:
normal/LSCS/instrumental
|
|||||
•
Birth weight
|
|||||
•
Outcome: abortions/full
term/premature/post term/Still born
|
|||||
•
Any congenital abnormalities
(specify)
|
|||||
•
If death of any child, mention:
age/sex and causes at the time of death
|
|||||
•
Age and sex of the family at
present if alive
|
|||||
•
Any complication in/after
pregnancy (within 42 days of child birth)
|
|||||
ii) Present Pregnancy:
•
LMP/period of amenorrhea:
•
EDD:
•
Date and place of registration:
•
No of IFA tablets consumed:
•
Reason for consuming <100
tablets:
•
Date of TT1 vaccination:
•
Date of TT2 vaccination:
•
TT booster:
•
Reason for not receiving scheduled
TT doses:
•
Plan for delivery: home/hospital/not
decide
9.
Antenatal visits and checks up details of present pregnancies
Particulars
|
Visit to health center/hospital
|
||||
1st
|
2nd
|
3rd
|
4th
|
5th
|
|
•
Date of visit
|
|||||
•
Objectives of the visit
|
|||||
•
Checkups by doctors/health workers
|
|||||
•
Height
|
|||||
•
Weight
|
|||||
•
Abdominal circumference
|
|||||
•
Fundal height
|
|||||
•
Positioning
|
|||||
•
Quickening
|
|||||
•
Lightening
|
|||||
•
FHS/fetal movement
|
|||||
•
BP
|
|||||
•
Pedal edema
|
|||||
•
Generalized edema
|
|||||
•
pallor
|
|||||
•
Investigation:
|
|||||
•
Blood group
•
Rh type
•
VDRL
•
Hb %
•
Urine: sugar/albumin
|
|||||
•
High risk pregnancies
|
|||||
•
Treatment prescribed if any
|
|||||
SINGATURE:
POST NATAL RECORD: F.F NO:
Date:
•
Name of the mother:
•
Date and time of delivery
•
place of the present delivery:
•
Type of delivery:
•
Sex of the baby:
•
Condition of baby at birth:
•
Presentation :
•
Birth weight:
•
Colostrums given with in:
Particulars
|
Visit to health center/hospital
|
||||
1st
|
2nd
|
3rd
|
4th
|
5th
|
|
•
Date
of visit
|
|||||
•
Checkup
done at home or hospital
|
|||||
•
Checkups
by doctors/health workers
|
|||||
•
Findings
|
|||||
•
Temperature
|
|||||
•
Pulse
|
|||||
•
Respiration
|
|||||
•
BP
|
|||||
•
Breast examination
|
|||||
•
Involution of the uterus
|
|||||
•
Lochia
|
|||||
•
Amount of bleeding
|
|||||
•
Homan’s signs: Yes/No
|
|||||
•
Episiotomy wound: healed/unhealed
|
|||||
11. Advice given about:
Particulars
|
Advice given
|
•
Initiation of breast feeding
|
|
•
Colostrums feeding
|
|
•
Exclusive breast feeding
|
|
•
Weaning
|
|
•
Nutrition-mother & child
|
|
•
Immunization
|
|
•
Cord care
|
|
•
Eye/Skin care
|
|
•
Bathing of the baby
|
|
•
Personal hygiene
|
|
•
Family Planning
|
|
•
Exercise
|
|
•
Episiotomy wound care
|
|
•
Any other issue being discussed
|
SIGNATURE:
NEW BORN RECORD F.F NO: Date:
Name:
Place of birth:
Date of birth:
Sex:
Birth weight:
Height:
Head circumference:
Chest circumference:
Reflexes:
-Sucking
-swallowing
-Grasping
-startle/moro reflex
-babinski
Parent name:
Nature of the delivery:
Colostrums given/not:
Type of feeding:
Zero polio date:
BCG date:
Date
|
Vital signs
|
Health assessment findings
|
Urine passed per day
|
Type of feeding and
frequency
|
Cord off
|
Umbilicus healed
|
Care/treatment
|
Heath education
|
Signature
|
RISK
FACTORS IF ANY:
SIGNATURE:
ADOLESCENT RECORD FF.NO: Date:
1.
Name:
3
.Present complaints: Yes/No. If yes , specify:
•
………………………………………….. b………………………………………………
c……………………………………………
d………………………………………………
4.Immunization:
a. Primary immunization completed:
Yes/No; b) TT-10 Yes/No c) Rubella vaccine for female: yes/no
5.a physical exercise: Regularly
/infrequently/No
b.Outdoor playing activities:Yes/No.
6. H/O of addiction; Yes/No. If
yes, specify: Gutka/ Pan masala/ Tobbaco chewing/Smoking/Alcohol/IV drug users/
Others;
A). Duration:
B). Reason for initiation:
7. Menstrual history (Females): Has
menstruation started: Yes/No, if yes go to next section
a. age at menarche………….yrs b.
Days/Interval:……………./………………
c. Menstrual cycle: Regular/Irregular
d. What is used during menstrual
period: cloth/pad/other
e. H/O white discharge: Yes/No.
8. a) Have you heard
about sexually transmitted disease: Yes/No
b. HIV&
AIDS: Yes/No c. If Yes, source of
information…………………………………...
9. Behavioral Issues (To be
asked from Parent/Guardian of the adolescent)
a. Is the adolescent’s interaction with
peers/neighbors/opposite sex normal? Yes/No
b, If No specify:
c. Is he/she currently going to school?
Yes/No; If Yes, does he/she have any difficulties in the school? studies/N d. If Yes
,specify:…………………………………………………
e. Eating disorders: Anorexia
nervosa/bulimia nervosa
10. Examination findings: General appearance: Normal/Undernourished/Obese
a. Pallor: Yes/No b.
Icterus: Yes/No c. BP: ……, d. Weight:
…, .e. Height:……., f. BMI…….
g.
Dental health: Good/Poor
11. Signs of puberty:
a. For Boys: Voice change/Testicular
enlargement/Pubic and axillary hair/Facial hair
b. For Girls: Breast enlargement/
Menarche/Public and axillary hair
12. Systematic examination: …………………………………………………………………………
SIGNATURE:
GERIATRIC RECORD F.F.
No: Date:
•
Name:
………………,
4. Presenting complaints:
Yes/No if yes, specify
a……………………………………………..
b…………………………………………
c……………………………………………
d…………………………………………
5. Any trauma/Surgery/Identified Chronic Diseases(Specify
duration and treatment):………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
6. H/o Addiction: Yes/No
If Yes, Specify: Gutka /Pan masala
/Tobacco Chewing/Smoking/Alcohol/IV drugs; Duration:………..
7. Psychosocial Issues:
a.
Mental changes: Memory loss, depression, any others:…………………………………………………
b.
Living with Spouse/Son/Daughter/Relative/ Others………………………………………………………
c.
Emotional disorders: Loneliness/Feeling of unwanted/Insecurity/Other………………………..
8. Activities of Daily Living (ADL):
a.
Toileting: Yes/No; b. Bathing:
Yes/No; c. Dressing: Yes/No; d. Eating:
Yes/No;
e.
Moving around: Yes/No, f. Voluntary
control over the urine and fecal discharge: Yes/No;
g.
transferring to and from the bed: yes/no
9. Independent activities of daily living (IADL)
a.
light house work: yes/no b. preparing meals: yes/no c. Taking medicine: yes/no
d.
shopping: yes/no e. using telephone:>
yes/no f. managing money: yes/no
10. General physical examination: general appearance:
normal/undernourished/obese
a.
weight(kg): ____ b. height(cm):
_____ c.
waist/hip ratio: ____________,
d. BMI:____, e. Pulse:____________, f
R/R.:______g. Temp:___________, h. BP:_______
i.
eye: pallor: yes/no. j. ictrus: yes/no
k. edema: yes/no. l. palpable lymph nodes: yes/no
11. SYSTEMIC EXAMINATION:
i). ORAL:
•
Number of teeth b. using dentures: yes/no c. oral hygiene: good/poor.
iii) EYE:
a.
visual acuity: b. using spectacles
for near vision: yes/no/ not available.
C. senile cataract: yes/no , matured/immature, operated/not operated
e.
glaucoma: yes/no
iv). ENT:
•
Hearing loss: yes/no if yes type:
conductive/sensory neural/mixed
c.
hearing aid: yes/no d. hearing
discharge: yes/no
v) . Respiratory examination:
vi). CVS examination:
vi). GI examination:
vii). Locomotors system:
viii). CNS examination:
ix). Integumentary examination:
x). Comments:
SIGNATURE:
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