HEALTH RECORDS MATERIAL & CHILD HEALTH
Item
- Title
- HEALTH RECORDS MATERIAL & CHILD HEALTH
- extracted text
-
■ CJD/A K frT. i
RF_COM_H_15_SUDHA_PART_1
*
C. S. I. M. K. D. MEDICAL SOCIETY COMMUNITY NURSING SCHOOL
HEALTH SURVEY CARD (FAMILY)
Family Folder Number:
Date of survey:
1.
NAME OF THE HEAD OF THE HOUSEHOLD: ‘
2.
ADDRESS:
TYPE OF FAMILY:
4.
RELIGION:
4.
STRUCTURE OF FAMILY:
Name
District:
Taluk:
3,
Serial
No.
House Number:
(Name of the house)
Village:
Relationship to
head of household
Age
Sex
2
Joint
1
Single
Educational status
Marital status
Occupation
1
2
3
4
5
6
7
8
9
10
6.
HEALTH STATUS.
Present
state of health
Serial No. of
the member
If any sickness in the past one year the nature and duration
Medical care
Approximate cost
1
2
3
4
5
6
7
8
9
10
Healthy.
1.
None due to want of facility.
4.
Ayurvedic.
2.
Sick—acutely.
2.
None due to poverty.
5.
Homeopathic.
3.
Sick—chronic.
3.
Allopathic..
6.
Others (specify).
1.
• •
2
6-a.
IMMUNIZATIONS (Note the date when done.1
Smallpox
Serial No. of
the member
A
!____ i riple Antigea
Revaccination
Primary
2nd I
1st
T. A B.
B. C. G.
Booster
3rd
Polio
1
2
I
£
3
I
I
4
5
6
7
1
8
9
10
a
7 a.
S. No. of
the mother
VITAL STATISTICS—BIRTHS.
Age at first
maternity
First pregnancy
iMedicsIcare Termination
Date of
termination ]
Third pregnancy
Date of
terminaton
Medical
care
Second pregnancy
Sex of child
Date of
Medical care
termination
Fourth pregnancy
Termina
tion
Sex of
child
Date of
termination
Sex of
child
Date of i Medical
termination
care
Medical
care
Termina
tion
Termination
Sex of
child
Fifth pregnancy
Sex of
child
Date of
termination
Medical
care
Sex of
child
Date of
termination
Medical
care
Termina
tion
Sex of
child
1
I
1
Sixth pregnancy
Date of
termination
Medical
care
Termins
tion
Seventh pregnancy
Termina
tion
Eighth pregnancy
Medical care:
1.
Hospital.
21
Trained Midwife.
3.
Untrained Midwife.
Tramination :
1.
Abrotion.
2.
Still brith.
3.
Alive now.
4
Termina
tion
Dead now.
Sex of
child
♦
I
3
7-b.
DEATHS.
(Since the time of inception of the family in 19..
Cause of death
Relationship with the
head of household
or any other
(Note S. No.)
Name of the deceased
Age at
death
Date of
death
Sex
Medical
care
Secondary
Primary
i
I
8.
ENVIRONMENT:
1.
(Draw a neat sletch on page 4.)
2
Detached
1
Type of building :
Attached
2.
3.
Roof:
4.
Walls :
5.
<1
<I
4
Plastered
2
Mud with dung plaster
3
Cement
Mud
1
Floor :
5
Tube well
1
Drainage :
Absent
9.
1
Rubbish :
Dumping
Latrine :
3
2
Pig Latrine
Open pit
10.
1
Strface
4
Closed pit
(c Water
seal slab
orE.S.P.)
11.
Rank vegetation:
13.
Mosquito breeding places:
2
Composting
3
Incineration
4
Scattered
(no W. S.
slab)
Dogs
Chicken
15.
Fly breeding places:
1
Present
(c”w. S.
Cats
Ducks
2
Absent
10
Conservancy
ft.
1
2
Present
Absent
Potential
Sheep
Mosquitoes
Others (specify)
Cows
1
Present
2
Absent
Potential
11
Any other
(specify)
flush out
slab)
3
Plenty
2
Absent
Actual
9
Urban
2
Present
Actual
Bielogical environment:
(Tick those present)
8
Septic tank
Distance from house
1
Present
14.
7
Board hole
2
Sanitary
Absent
4
Soakage pit
(c no W. S.
slab)
1
12.
9
Others
(specify)
8
Piped
(chlorinated)
3
Kitchen garden
6
Bored hole
Insanitary
4
Electric
2
Present
5
Closed pit
1
Cattle shed:
4
Others (specify)
7
River
6
Thank
6
Others (specify)
5
Wood
3
Kerosene stove, etc.
2
1
Not functioning
Functioning
Smoke out let
Kitchen :
Others (Specify)
3
Brick
2
1
Thatch
4
3
Concrete
2
Tiled '*’*
1
Thatched
7. Drinking water :
4
3
2
1
Unprotected
Protected
Unprotected
Protected
Community well
Family well
8.
near complete
of the total ground area.
Mud
6.
4
3
2
1
Built-in area :
Goats
Flies
4
9
FINANCIAL INFORMATION:
Rs.
Rs.
Monthly family income from:
Monthly family expenditure for:
1.
Salaries and wages
1.
Food
2.
Land and agricultural products
2
Clothes
3.« Education
3.
Buildings
4.
Business
5.
Livestock
6.
Other items (Specify)
4.
Medical care
5.
Rent or/and mortgage
6.
Tax
7.
Debts—interest
Repayment
8.
Any others (specify)
TOTAL
TOTAL
■ i
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Com h
’ 2—
F. F. No,
C. S. I. HOSPITAL, PALLOM COMMUNITY HEALTH SERVICE
FAMILY RECORD
Religion-
Name of Family—
Date
Address
«•
Family
S
Group
Type of House
___________________
o E
o
Roof | Walls (Floor Rent
IZ
TilTh|Te|M|Br|Pl M Ce
Directions
Marital Status
Place of
Birth
| M | W j Sep | Div
—Village
Sub centre
Date of
Birth I| Schooling
Type
Latri
ne
Typ
Source
water Drain Vent Smok
out
Physical Conditions, (if dead, date & cause)
M
W(1)
T T)
W (3)
Children and Still birth
1
2
3
4
5
6
7
8
9
10
Others in household
*
Sex Address if not home
I
Year of
Birth
Relationship to Head
of family
Sex
Year of
Birth Sex
Others in Household
Relationship to Head
of family
I
Comfort
Economic Status.Good
Date
Occupation
Farnings
I Regular
or
I_ Seasonal
Other
Income
Source
Necessities
Poverty
Debts
Properties Owned
Date
Man
Woman
Woman
Children
House
Land—Wet
-Dry
Cattle
Poultry
Furniture
Others
Date
Date
Date
Record of Services
Date
Name of patient
$
Diagnosis
Clinic
House
Hosp.
Type
Fee
Remarks
Date
Closed
Condition
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POSTPARTUM
DOCTOR'S ODERS:
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NEW BORN
Sex:
Birth weight:
Name
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Condition of Baby
Length:
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Full Term
rth Reported By
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Date
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RORES PROJECT HOUSEHOLD SURVEY QUESTIONNAIRE
SRINIVASAPURA, KOLAR DISTRICT
Date of interview
Name of Interviewers and designation
1.
2.
3.
I
1.
2.
3.
4.
SI. No.
Name of head of the family
Name of the village
Religion
I I 1. Hindu
CU 2. Muslim
O 3. Christian
5.
6.
Name of the caste
Name of the category
L_J 1. SC
D 2. ST
D 3. BC
HOUSING AND ENVIRONMENT
7.
Do you have a own house?
8.
If yes, How many:
9.
Type of housing
I—I 1. Terraced
2. Tiled
I I 3. Thatched
10.
Do you have electricity?
I
| a) Yes
O b) No
11.
Do you have Biogas?
I
O b) No
12.
Do you keep the cattle in the living room
| a) Yes
a) Yes
D b) No
13.
Do you have a separate kitchen?
I
I a) Yes
O b) No
14.
How do members of the house dispose
human waste?
15.
Do you have closed pit for waste water disposal?
J 1. Latrine
I I 2. Open field
D a) Yes
D b) No
16.
Is there stagnant water close to this
house? (within 50 feet)
O a) Yes
D b) No
17.
Water supply :
I
|
| 1. Community owned
| 2. Household (self)
18.
Source:
I
| 1. Open well
Distance within:
| | 2. Tap
O 3. Borewell (hand pump)
O 1. lOOfeet
19.
I
I a) Yes
b) No
Nos.
O 2. 200feet
O 3. beyond
1
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LANDHOLDING & ASSETS
21.
a) Does this family own any land
22.
If yes,
1. Own Land
2. Government Land
23.
24.
a)Yes
D b) No
Guntas
Guntas
Total
Land usage pattern:
1. Dry Land
2. under Pump Irrigation
Guntas
Guntas
Guntas
Guntas
Guntas
3. Under Tank Irrigation
4. Under Orchard
Number of Live Stock you have?
1. Cross bred milch cows
2. Local bred milch cows
3. Oxen
4. Sheep
nos.
nos.
nos.
nos.
nos.
nos.
nos.
5. Goat..
6. Poultry
7. Piggery
8. Others (specify)
25.
Do you have any annual income yielding trees?
26.
If yes
— Nos.
b) No
a)Yes
Name of the trees
Numbers
Annual Income
Rs.
1.
2.
3.
Total
27.
Do you have mulberry cultivation?
28.
If yes, number of guntas under mulbery cultivation
29.
Does this family go for agricultural wage work
O a)Yes
30.
If yes,
31.
Do you have a radio?
|
|
I
32.
Do you have a TV?
33.
Do you have the following
I
I a)Yes
I
I b) No
Guntas
| 1. Occasional
| 2. Regular
| a) Yes
a) Yes
O b) No
O b) No
b) No
I—I 1. Bullockcart
EZ1 2. Bicycle
O 3. Motor cycle/Scooter
4. Tractor
D 5. any other (specify)
3
HEALTH AND NUTRITION
34.
What do members of the household do for the following problems?
Hospital
Local Medicine
edicine
a) Common illness _________________ __________
b) Cuts and injuries____________ ______________
c) Diarrhoea _____________________ _________
d) Dog bite
e) Snake bite
_________
f) Jaundice
g) Bone Setting
NOTE: Common Illness : Fever, Cold & Cough, Aches and Pains
Ol. Dai
□ 2. ANM
I 13. Family member
35.
Who delivered the children in your house?
36.
Where were the children in your house born?
37.
Has any one in the family visited Government Health Centre
|
At home
|2. Hospital
□ a) Yes
O b)No
□ a)Yes
b) No
O a) Yes
O a)Yes
b) No
b) No
□ a) Yes
b) No
43.
grade evening temperature)
Has any one in the family got discoloration of skin with loss
44.
45.
46.
of sensation
Does any one in the family have seasonal cough with wheezing
Does any one in the family get convulsions
Has any one in the family died during the past one year?
I I a)Yes
□ a)Yes
O a)Yes
O a)Yes
b) No
b)No
b)no
b)No
during the past one year?
38.
If yes, reasons
1.
2.
39.
3.
Has the health worker visited your home during the past one year?
40.
If yes, reasons
1.
2.
41.
3.
Do any women in the house have the following problems
1. Menstrual problems
43.
2. White Discharge
Does any one in the family have the following symptoms?
(Chronic cough with blood in sputum, Loss of weight and Low
4
47.
If yes,
Age
Sex
Reasons
1.
2.
3.
48.
49.
50.
Is any woman in the family pregnant now
I
I
Do you have a disabled person in the family?
If yes,
Age
| a) Yes
| a)Yes
Sex
O t>) No
O b) No
Type of disability
1.
2.
3.
51.
No of people who use tobacco in the family
1. Chewing
2. Smoking
52.
Nos.
Nos.
No. of people consume alcohol
1. Occassional
2. Regular
Nos.
Nos.
NUTRITION
53.
54.
O 1. Red
O 2. Green
What is the colour of the ration card you have?
I | 3. No Ration Card
O 1. Rice & Ragi
What are the rations you get regularly?
□ 2. Wheat
I I 3. Sugar
O 4. Edible Oil
O 5. Kerosene
J
55.
Do you have kitchen garden?
56.
How much milk does your family consume in a week
57.
How many kilograms of pulses your family consume in a week
58.
How much vegetables and greens your family consume in a week?
59.
Is there any one in the family a member in any of the RORES sanghas
If yes,
60.
O a) Yes
Ltrs.
1. Name of the person
2. Name of the sangha
61.
|□ b) No
Kgs.
|
----------
Kgs.
| a) Yes
|
| b)No
_______________________
_______________________
In the opinion of the interviewer which group does this family
fit into
O 1.Definite target
I
I 2. Non-target
O 3. In between
5
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RORES PROJECT HOUSEHOLD SURVEY QUESTIONNAIRE
SRINIVASAPURA, KOLAR DISTRICT
Date of interview
Name of Interviewers and designation
1.
2.
3.
1
1.
2.
3.
4.
SI. No.
Name of head of the family
Name of the village -------Religion
I I 1. Hindu
□ 2. Muslim
O 3. Christian
5.
6.
Name of the caste —
Name of the category
LJ 1. SC
D 2. ST
O 3. BC
HOUSING AND ENVIRONMENT
i
I
t
I
I a) Yes
7.
Do you have a own house?
8.
If yes, How many:
9.
Type of housing
I—I 1. Terraced
O 2. Tiled
I I 3. Thatched
10.
Do you have electricity?
I
| a) Yes
O b) No
11.
Do you have Biogas?
12.
Do you keep the cattle in the living room
I | a) Yes
O a) Yes
O b) No
O b) No
13.
Do you have a separate kitchen?
I
O b) No
14.
How do members of the house dispose
human waste?
15.
Do you have closed pit for waste water disposal?
J 1. Latrine
I | 2. Open field
D a) Yes
O b) No
16.
Is there stagnant water close to this
house? (within 50 feet)
□ a) Yes
□ b) No
17.
Water supply :
I
| 1. Community owned
|
| 2. Household (self)
I
| 1. Open well
|
| 2. Tap
3. Borewell (hand pump)
□
1. lOOfeet
18.
19.
b) No
Nos.
Source:
Distance within:
1
I a) Yes
2. 200feet
3. beyond
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LANDHOLDING & ASSETS
21.
a) Does this family own any land
22.
If yes,
1. Own Land
2. Government Land
O b) No
O a) Yes
Guntas
Guntas
Guntas
Total
23.
24.
Land usage pattern:
1. Dry Land
2. under Pump Irrigation
3. Under Tank Irrigation
4. Under Orchard
Number of Live Stock you have?
1. Cross bred milch cows
2. Local bred milch cows
Guntas
Guntas
Guntas
Guntas
nos.
nos.
nos.
3. Oxen
4. Sheep
5. Goat..
6. Poultry
7. Piggery
8. Others (specify)
nos.
nos.
nos.
nos.
25.
Do you have any annual income yielding trees?
26.
If yes
Oa)Yes
Numbers
Name of the trees
1.
2.
3.
— Nos.
b) No
Annual Income
Rs.
Total
I
| a)Yes
[_| b) No
27.
Do you have mulberry cultivation?
28.
If yes, number of guntas under mulbery cultivation
29.
Does this family go for agricultural wage work
I I a)Yes
O b) No
30.
If yes,
31.
Do you have a radio?
32.
Do you have a TV?
' ] 1. Occasional
| | 2. Regular
I | a) Yes
D a) Yes
O b) No
O b) No
33.
Do you have the following
Guntas
1. Bullockcart
I I 2. Bicycle
O 3. Motor cycle/Scooter
O 4. Tractor
A 5. any other (specify)
3
HEALTH AND NUTRITION
34.
What do members of the household do for the following problems?
Hospital Medicine
Local Medicine
a) Common illness
b) Cuts and injuries
c) Diarrhoea
d) Dog bite
e) Snake bite
f) Jaundice
g) Bone Setting
NOTE: Common Illness : Fever, Cold & Cough, Aches and Pains
35.
Who delivered the children in your house?
□ 1. Dai
02. ANM
I I 3. Family member
36.
Where were the children in your house born?
21L At home
| |2. Hospital
37.
Has any one in the family visited Government Health Centre
38.
during the past one year?
If yes, reasons
I
I a) Yes
O b)No
1.
2.
3.
39.
Has the health worker visited your home during the past one year?
40.
If yes, reasons
b) No
1.
2.
3.
41.
43.
43.
44.
45.
46.
Do any women in the house have the following problems
1. Menstrual problems
2. White Discharge
Does any one in the family have the following symptoms?
(Chronic cough with blood in sputum, Loss of weight and Low
grade evening temperature)
Has any one in the family got discoloration of skin with loss
of sensation
Does any one in the family have seasonal cough with wheezing
Does any one in the family get convulsions
Has any one in the family died during the past one year?
4
O a) Yes
□ a)Yes
b) No
O a) Yes
b) No
I I a)Yes
O a)Yes
□ a)Yes
I b) No
D b)No
O b)no
EZJ a)Yes
D b)No
b) No
47.
If yes,
Age
Sex
Reasons
1.
2.
3.
48.
49.
50.
Is any woman in the family pregnant now
Do you have a disabled person in the family?
If yes,
Age
Sex
1.
2.
I
|
| a) Yes
| a)Yes
□ b) No
O b) No
Type of disability
3.
51.
No of people who use tobacco in the family
1. Chewing
2. Smoking
Nos.
Nos.
52.
No. of people consume alcohol
1. Occassional
2. Regular
Nos.
Nos.
NUTRITION
53.
54.
I I 1. Red
O 2. Green
What is the colour of the ration card you have?
I | 3. No Ration Card
O 1. Rice & Ragi
What are the rations you get regularly?
□ 2. Wheat
I I 3. Sugar
O 4. Edible Oil
O 5. Kerosene
I
I a) Yes
IO b) No
55.
Do you have kitchen garden?
56.
How much milk does your family consume in a week
57.
How many kilograms of pulses your family consume in a week
58.
How much vegetables and greens your family consume in a week?
----------
Kgs.
59.
Is there any one in the family a member in any of the RORES sanghas |
| a) Yes
|
60.
If yes,
1. Name of the person
2. Name of the sangha
61.
In the opinion of the interviewer which group does this family
fit into
Ltrs.
Kgs.
O 1.Definite target
5
I
I 2. Non-target
I
I 3. In between
| b)No
62.
Other than agricultural and allied activities, do you have any other source of income?
Income in a year Rs.
Nature of source
63.
Does your household have any debts?
I | a) Yes
64.
A
X
65.
□ b) No
If yes how much? and source.
Source
Private lender
1.
Bank loan
Co-operatives
3.
4.
Sanghas
Others Specify
5.
Amount
Rs.
Rs.
Rs.
Rs.
Rs.
How many cart loads of farm yard manure does your family generate in a year?
Cart loads.
66.
What type of chemical fertilizers and how much do you use in a year?
Quantity used in kgs.
Name of the fertilizers
1.
3.
67. Do you give any special care/diet to pregnant women?
□ b) No
68.
If yes what type diet/care given
Special diet given
special care given
69.
Does your family have any taboos in food practice for pregnant women?
□ b) No
70.
If yes what are the taboos?
71. What are the common illnesses you find among the U/5 children
1.
2.
3.
4.
5.
72.
Up to what age children in your family wcrc/are breast fed?
73. At what age you start supplementary food to your children?
74. What type of supplementary food you give to your children?
75. How many times a day normally you take food?
‘
76. How many days in a year you take less than your normal intake due to nonavailability of food?
No of days
Month/scason
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ST. MARTHA’S HOSPITAL
ANTE NATAL CARD
Name
Age
Hosp. No.
A/N No.
Husband's Name & Address
Yrs. Married
L.M.P.
E.C D.
Menstrual Cycle
Gravida
Para
Date of Adm.
Date of Discharge
Previous Med. History
Obstetric Med. History
Pelvic Examination
Height
Tet. Vac. 1st. Dose/2nd. Dose
Investigations
C. V. F.
R. S.
Breast
Date
Wt.
Urine
Alb. Sugar
B.P.
Hb.
OED
Palpation
F.H.
Remarks & T.R.
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CHILD HEALTH RECORD
Family Number .
Village
Name
Age/DOB
Sex
M / F
Breast fed tiff
Age at supplementation
Type of first supplement
Special Problems :
Date
Hb
4....
Date
Hb
IMMUNIZATIONS
Small pox
Primary
BCG
Others (specify)
Revaccination
Triple Antigen
Vitamin A
■;
1st
5.
2nd
2.___
6.
Booster
3--------
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Polio
1st
2nd
Booster
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FOLLOW-UP (ANTE-NATAL)
Family Number
Name
T
Date
Weight
Oedema
BP
Height of
uterus
Pres and
Pos
FH
Clinical details
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FOLLOW-UP (POST-NATAL)
Name
Date
Family Number
Weight
Lactation
Complaints
Treatm
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FOLLOW-UP CARD (CHILDREN)
Family Number
Name
Weight
Date
i
Deficiency
signs
Complaints
Treatment
Con<7 H
UNDER FIVES’ CLINIC
No.
Name
Month of Birth
Date
Address
Weight Symptoms and their Duration
-7^
V.
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Treatment
H
PRIMARY & MIDDLE SECTION
NATIONAL HIGH SCHOOL
BASAVANAGUDI
:
:
3d
7^
BANGALORE-560004
STUDENT HEALTH RECORD
Reg. No.
PHYSICAL EXAMINATION
Date of Birth.
Name Chi
5
-8|
Name and address of Father or Guardian
Important family History :
Previous Illnesses & Operations :
Examining Doctor
Class & Year
Date
Height
Weight
Chiest :
Full Inspiration
Full Expiration
B. P.
Blood Group
Check V
findings are normal after examination, if abnormal
Mark x and describe on the reverse page.
Skin
Eyes
Ears
Nose
Throat
Teeth
Thyroid
Lymph Nodes
Breasts
Lungs
Heart
Abdomen
Skeletal System
Nervous System
Genitalia
Other
[P.T.O. ]
J
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................ . I
Record of Illness
Date
Complaints, Physcical Examination, Diagnosis and Treatment
Corn h
c umulative
h ealth
record
Name s
Permanent address ?
Occupation s
Date and place of birth’
Annual incomes
Father's names
Health status?
Mother's names
0 rot hers s
Father
Sisters?
Mot her
Past illness of the child?
■4----------- -----------------
Immunization
1
1.
1.2.
! Dat e
Dat e
;
3
•Dat e
4
Dat e
5
Small pox
Primary vaccination
i
Re-vaccination
I
I
I
B.C.C. Vaccination
j
So
Triple Immunization •
4.
Diphtheria—T etanus—Immunizat ion
5.
T.A.Bo „
6O
Cholera
7.
Poliomyelitis
So
Any' other (specify)
■
I
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--------------- • •
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1. HEDICA-L EXAI'lINA'lDN (t
by
by
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4
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doctor)
See Code
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ii
4------------
IV
Date and year
Name of school
i
Standard studying
Age
I
Height
Weight
Chest measurements Inspiration
Chest measurements Expiration
Ma Inutrition
I
Qeficiency diseases
Anaemia
Skin diseases
T eeth
/
. t.
'
*
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2
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£ontd. from pre-page
11
>
IV
III
---- 7
Gums
Nose
I
Adenoids
Tonsils
I
I
N = Normal
Code
I
II
III
C = corrected
0 s*. Defective
At the ent erance of the chile to I standard
Before leaving the IV standard
Before leaving the VII standard
MEDICAL EXAMINATION (to be filled by a doctor)
I
III '
I
Glands - Submaxillary
C
Thyroid
Others
I
I
*
Ear diseases
<•
Hearing - R
L
♦
I
Eye diseases
Vision
IB
I
Orthopaedic diseases
• I
strabismus
See Code
i
i
I
R
L
*
Heart - Organic diseases
Functional
Lungs
Liver
a
Spleen
Hernia
>
Speech defects
Nervous system disorders
I
Allergic diseases
Mental developments
Hydrocele
►
Phymosis
Fitness for PT and games
Initials of Medical Officer
I
I
Initials of parent/guardian
Advices
4 -
Position: 3733 (2 views)