RF_CH_14_SUDHA_PART_ 1.pdf
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RF_CH_14_SUDHA_PART_ 1
NATIONAL INSTITUTE OF NUTRITION
INDIAN
COUNCIL OF MEDICAL RESEARCH
H Y D E R A B A D - 500 007
Z?T? J.
,
FAMILY
O
)
fl
C C.T^C^O
FOLDER
FAMILY NO.
HOUSE HOLD NUMBER
NAME OF THE HEAD OF THE FAMILY
COMMUNITY
S. No.
FAMILY INCOME
OCCUPATION
• Name
Age/DOB
Sex
Relationship
Literacy
Income
Remarks
1
2
3
4
5
6
'W 7
8
-
9
10
REMARKS
*
BIRTHS
No.
Date of delivery
FT/PM, LB/SB Home/Hospital
If Home/Dai/ANM
Remarks
Cause of death
Remarks
DEATHS
No.
Name
i
i
■>
Date
Age at Death
ST. JOHN'S MEDICAL COLLEGE & HOSPITAL
MEDICO - SOCIAL UNIT
gZPARTME^r OF WOWE & SOUAl MEDK1HE
MEDICO - SOCIAL CASE RECORDS
A. FAMILY SCHEDULE
1.
I.
4.
2.
5.
Village
Family No.
IDENTIFICATIO N
Locality & Basti
Head of the Family
3. House No.
6. a : Religion :
6. b: Caste
II. HOUSING
House Type &
Ventilation :
7. Owned / Rented
8. Roof: Thatched / Tiled / Brick I any other
9, Walls : Thatched I Mud / Brick / Stone / other
11. [a] No. of Rooms :
12. [a] No. of Windows :
13. [a] Kitchen + —
Natural :
Good / Moderate / Poor.
10. Flooring : Mud / Stone / Cement / other
11. [b] Floor Area [F] :
12. [b] Window Area [W] :
13. [b] Type Oven : Smokeless / other
15. Electricity
+
—
11. [c] Floor area per person :
W
— 12. [c] Good / Medium / Poor
16.
Other: Oil lamp / Lantern Glass lamp
Lighting :
14.
Cleanliness :
17. [a] Interior ; Clean / Moderately clean / Dirty
17. [b] Maintenance : Repairs attended / White washed [frequency].
Sanitation :
18. [a] Latrine + — Flush / Septic T / Waterseal / Borehole
Open space / Dry / Other [specify]
18. [b] Private / Common.
Water Supply : 19. [a] Well +
20. [a] Tap +
21.
Tank +
22.
River +
— Sanitary / Insanitary.
19. [b] Drawn by pump / pully and rope.
19. [c] Private / Common
— [Mention source of water]
20. [b] Private / Common.
—1
— j [Note approximate distance
23. Drinking....................................... '....... Bathing. .............................................. Washing.........................
' from the house]
24. Cots / Chairs / Tables / Radio / Cooking utensils : [Earthen / Metallic / Both / other [specify]
Material
+ — + — +----- t- —
•
Possessions :
Nos.
—
.
■ .
.
—
Front
Rear
Side.
Surroundings :
25. [a] Open space
25. [b] Clean / Weedy / Kitchen garden
25. [c] Sanitary or insanitary pits / other.
[specify]
+
—
26.
Compound wall .
+
—
27.
Drainage
+
—
28. [b] Attached / Detached.
28. [a] Animal shed
,
+
—
Pests :
29. Bugs I Mosquitoes / Rats / others [specify]
(’) III.
30.
(•*)
SI.
No.
1.
HOUSEHOLD
MEMBERS.
NAME OF THE INFORMANT:
[••’J
Relationship
to the head of
family.
Date
NAME
Sex
Age
Birth
2.
3,
4,
5.
Health Status
Literacy
Marital
status.
Personal
1 habits ><
smoke, snuff,
chewing,
drinks etc.
(frequency / day)
T.B. Leprosy,
. - Diabetes-,
Pregnancy
Lactation etc.
Speak Read Write
X
(Mo ther tongue)
1 '
7,
8.
9.
6.
..
10,
11,
Occupation
Main
Subsidiary
INCOME
13.
12.
J5.
14.
3.
4.
t
!>
5.
6.
7.
S.
9.
JO.
II.
12.
(*) All persons partaking meals from the kitchen should be included.
cards.
If there are more than one family with separate kitchen but having a common roof, a note be made to that effect against the family number on respective
(**’) Principal bread-earner in the family.
(**) Names of children should, preferably be written as per their birth order.
IV.
MORTALITY
IN
THE
x Note language (s) in addition to mother tongue
FAMILY
(Deaths of dependents on the head of the family e.g., Parents, Wife, Husband, Siblings, Offsprings etc.)
31.
SI.
No.
1.
NAME
2.
~~~
"
PARTICULARS:
Age
3.
Date
of
Birth
Sex
4.
5.
Relationship
to
head
Birth order of
the child
6.
7.
Probable cause of
Death
8.
Attended By
‘S’ I
Physicians.
9.
10.
Approximate
duration of
illness before
death
Whether death
is registered
in village
register.
II.
12.
V.
32.
LANDS :
(Acres)
[a] A^a owned
[b]
[c] Aiea cultivated :
/
-
33.
Arc(-i cultivated
MAIN CROPS :
Frequency / Year
Own
POSSESSIONS
Dry
Wet
Total
Dry
Wet
.............................. Total
Tenancy
Yield per year
34.
..................................................................... Total
DOMESTIC
Paddy
Cows
Jower
Buffalos
ANIMALS
Numbers
Milk yield
per animal
For the past one year
Quantity
Quantity
Sold
consumed
Pulses
Oil Seeds
Poultry
....Eggs
................
...............
Sugar
Piggery
.......
...............
...............
Cotton
Bullocks and
Hc-buffalos.
Other animals
and Pets.
.......
...............
................
Vegetables
Fruits
Others
VI.
35.
TOTAL INCOME:
36.
EXPENDITURE (Approx)
[From all sources]
[a] Food
[b] Medical aid
INCOME AND EXPENDITURE
P M. / P.A.
LeJ Smoke, Snuff, Chewing, Drinks
[fl Conveyance
[g] House rent
^
37.
SAVINGS :
38.
DEBTS:
[c]
Education
[d]
Clothing
+
—
Corn H I
•
•
Form No.
ST. MARTHA’S HOSPITAL, BANGALORE-9
Family Record
Address :
Name of head of the family :
Age :
Joint/Single
FAMILY HISTORY :
SI.
No.
Relation
Name
Age
Sex
1.
2.
3.
4.
5.
6.
7.
*
8.
9.
\
10.
11.
12.
FAMILY HEALTH CONDITIONS-Children under five years
SUMMARY OF THE HEALTH CONDITION OF THE REST OF THE FAMILY
«
CELL
•'■O.tb ■ 5G0 001
Occupation
Wage
.
IMMUNIZATION RECORD OF THE FAMILY
Si.
No.
Name
Small Pox
B.C.G.
T.A.B.C.
Polio
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
HOME AND ENVIRONMENT CONDITION
No. of rooms and condition
R-ent
Pacca / Kacha
Environment
Light arrangement
SOCIO ECONOMIC
Any Extra Income
Any Debt
Saving
Average Daily Expense
SOCIAL PROBLEMS OF THE FAMILY (Is family staying together)
NUTRITION & DIET HABITS
Average daily diet
Vegetarian
Water Source
Nonvegetarian
D.P.T.
COM H V-r'l
DEPARTMENT OF PATHOLOGY, ALJ. INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI-110016
CYTOPATHOLOGY CONSULTATION FORM-TEACHING BLOCK, FIRST FLOOR, PHONE NO. 393
PATIENT’S NAME
(Print clearly)..........................................................
Father's/Husband's
name.............. I.......................................................
ospital Registration
number _____________________ ___________
SEX
ROOM 1069
MARRIED/SINGLE
CATEGORY
AGE
Routine
Room/Ward/OPD/Clinic
Rush
Signature of resident...
(Must be signed verifying accurate and complete
information)
Phone No.
Chief of Clinical Unit......... .......................
Bed No
Name of Resident (Capital letters)
SPECIMEN COLLECTED ON (DATE)
AM/PM
AT
HEPARIN
YES
NO
TYPE OF SPECIMEN
GYNEOLOGIC-OBSTETRIC
Fast (Combined 1 slide :
vaginal-endocervical)
FOR ROUTINE SCREENING
Vaginal :
CL
pool
Exocervical
<
Endocervical
H
Endometrial
wall
irrigate
swab
scrape
Other
swab
scrape
aspirate
aspirate
brush
URINARY
BladderQVoided
Ureter :
Rt.
Pelvis :
Rt.
|
catheterized
Lt.
Lt.
PULMONARY (Series-5 sputa)
Sputum :
early a.m.
other
(No in series : I-2-3-4-5)
Bronchoscopy :
ALIMENTARY TRACT
Oral (buccal, gingi
val)
sinuses
Nasal
Pharyngeal
Esophageal
Gastric
Duodenal
Small intestine
Large Intetine
swab
aspirate
FLUIDS
Abdominal
Pleural
Rt
Lt
Pericardial
Cerebrospinal
Ocular :
Rt.
Lt. (type . ...)
Nipple :
Rt 0 Lt.
Prostatic
Other
irrigate ; of
V)
HISTORY (all pertinent data)
1
mAnctrnal neriod........
Expected date of delivery...,
Type
Yes No
Therapy_
Endocrine
Radiation
Surgical
Other
Biopsy :
Previous date ........................... Surg Path No
. .......
Diagnosis
................................. ....................
Smear :
Previous date
Cytopath. No
.
Diagnosis
Special information desired :
Do not write below this line
CLINICAL DIAGNOSIS :
Cytopath Number
Cytopathology Report
,.......
Specimen Received
O
-j
O
u.
oz
oQ
CANCER
CATEGORY
NEG]
There is no evidence of cancer In this specimen.
INCj
Further evidence as indicated is needed to rule cancer in or out.
IPO?
REPORTED ON
Diagnostic for cancer-carry out further identity and localization of lesion as indicated
M.D.
(Pathologist)
Clinic
rfradarf rfcD
'-J
M or F
Name
tdrfdo
rlorfo ecissa
Date of birth
Date of first seen
oioU.ri orf.............
•J
...... sSjtrfrf; zn>o aorf saotsoa..................
Father’s Name
docSoia a3?icjO
Mother’s Name
OTCWOjO aSpttdo
Address
ngdorf esarirf avarf
CHILD
HEALTH
RECORD
MALLUR HEALTH COOPERATIVE
£
Family Folder No
Clinic
3
No
St. Johns Medical College
?,
F
CHILD’S HEIGHT AND
WEIGHT RECORD OVER
THE FIRST FIVE YEARS
2^3
5
dd
REASONS FOR SPECIAL CARE
ad,u Serfs
SOCTD-ECONOMIC
STATUS
OF
TAMIL?
MECHANICAL POSSESSIONS
HOUSING
Construction
Walls
Floor
Roof
House
All brick/mixed/all mud
Paved/dung/other
Brick/thatch/other
Owned/rented
Number of Rooms
Electricity
ANIMALS
Oxen
Cows
Buffaloes
Goats
Camels
Hens
SOURCE OF INCOME
i.e. land, occupation, trade etc.
SANITATION
Water Supply
Drinking
Other Uses
Private
Joint
Open Well
Hand Pump
Tube Well
Tap
— — — ----- ..
Distance of Drinking water
from animals...................
from latrine...................
Disposal of Wastes
Drainage
None
Into Street
Soakage
Latrine
Field or street
Open pit
Water seal
Septic tank
Sou U01
G . C-
Separate cattle shed
Shed away from home
Ei/sik
in living room
Separate room
COMMUNITY HEALTF! CELl
In house
4 7 /1 , ( f ir .. •oo.-)S C. M arks Hoad
Other
Animals Kept: —
boat
bozcuscsj
b* — feLGEunucX
g — 2Cgl!|g
pj — nGUobsnzG
^^glijicX
kg
— KGAsrcqusrciou
bK' — bu.IUJ3LX
22 — 26COUCPL^
1
J
OU |I?C
guclX
Ko*
D3CG O(
pcsq o( pLUi|X
KGJFCIOU to
HV WE
rial
Ofc
kV Hl TA
HEWB EK?
qgf6 o( piLtp
OU |I?C OL
ySG sc guclX
ol 22-
rr noHosb-
C3LG b’ b°2C W’2‘
El iSlP|G (OL
WVlEKMVr
b°L fb*
El.iSfPIG
inCD
A32
inp
bVWlTA brVMMIMC
COUA
KG
btf
2UJ3| box
Dbl
11
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pG3|fp zcscnz 6CCcgnzc O( qcacp
D$rr6 o( qcarp i( [<uomu
E E W V K K 2
NAME
................................ VILLAGE..?:..'™
Occupation of Head of Family
...............
BLOCK...
.DISTRICT.
......HOUSE NO
FOLDER NO
Worker’s Name
I.
II.
IDENTIFICATION.
Village.
2.
4.
Name.
5. Husband’s Name.
Age :
2.
Occupation of the woman.
Income.
3.
Husband’s Occupation.
4.
Income.
2.
Age at Marriage
3.
Age at Co-habit.
Consanguinous
marriage. Yes/No.
4.
Reaction to Family Planning : Not aware/
Resistant/Wil ling/Practising.
DIETARY HABITS.
1.
V.
6.
MARRIAGE PARTICULARS.
1.
IV.
3. Family No. (A-Schedule)
OCCUPATIONAL STATUS
1.
III.
Sr. No. O. Schedule.
1.
Main Staple food.
Rice/Wheat/Maize/Jowar.
2.
Vegetarian/Non-Vegetarian:— Meat/Egg/Fish/(Frequency)
4.
Tetanus Toxoid (During pregnancy)
IMMUNIZATOIN.
Fiist dose.
1.
Last Small Pox Vaccination,
2.
Last Cholera Vaccination
Second dose.
3.
Last Typhoid Vaccination
Third dose.
VI.
PAST MEDICAL ILLNESS.
VII.
MENSTRUAL HISTORY.
1.
Age at menarche.
VIII.
PRESENT COMPLAINTS.
IX.
NUTRITIONAL DEFICIENCIES.
2.
Previous cycles.
Regular/Irregular.
Xerosis or Bitot spots
Night blindness
Angular stomatitis
Glossitis
Nutritional oedema
Anaemia
Osteomalacia
Parasthesias
Peripheral Neuritis
3.
Flow: Normal/Scanty/Heavy.
X.
GENERAL EXAMINATION :
XIII.
PREJjfcUS
Height.
Liver.
Weight.
Spleen.
Preg.
(Sr, No.)
Temp,
Gums.
(1)
Pulse.
Teeth.
1.
B P.
Lymphglands.
C. V. S.
Oedema.
Resp. Syst.
Others.
Term of preg. Home Hospital
Institutional
(2)
2.
(Spec
3.
Ascitis.
4.
XI.
INVESTIGATIONS:
1. Blood:-
5.
Hb%
Blood group:
6.
R. H. factoi.
7.
V.D. R. L.
2.
Urine:-
Albumin.
8.
Sugar.
Microscopic.
3.
Stool:-
9.
Ova.
10.
Cyst.
Mucus.
4.
11.
Other Special Investigations:
Vaginal cytology
12.
Others.
XII.
OBSTETRIC HISTORY.
1.
Gravida
2.
Para.
3.
L. M. P. |
4.
E.D.D.
(3)
OBSTETRICS
HISTORY
Mode of
Delivery
Asso.
Disease
(4)
(5)
Child
Alive/dead Cause of Death
(6)
(7)
%
Date
Wt.
Hb%
Urine
Al. Sug
Heart
lungs
Breast
XIV.
ANTE-NATAL FOLLOW UP
Oedema
Ht. of
Uterus.
B. P.
4
«
Persentation
Position
F. H. S.
Due
visit
Treatment
•
0
1
■
XV.
Pelvic Examination
XVI.
Arrangement for confinement
i
____
XVII.
XVIII.
LABOUR RECORD.
4. Date of delivery.
1.
Delivery conducted at Home/P.H.C./Referal/Hospital.
5. Total duration of labour.
2
Mode of Delivery Normal/forceps/vacuum/C.S./Destructive.
6. Commencement of labour pains.
3.
Delivery conducted by :
7.
8. Time of delivery of baby.
FOETAL OUTCOME :
(1) Abortion/Premature/Fullterm.
(2) Still birth/Neonatal death.
(3)
Rupture of membrane.
Birth weight :
(4) Sex :
(5) Congenital malformations : Hydrocephalus/
Anenecphaly/Meningocele/Talipus.
9.
Time of delivery of placenta.
10.
Perineum:- Intact-Laceratiou-Episiotomy.
11. Total blood loss.
12. Condition of the mother soon after delivery.
Birth injuries :
XIX.
XX
POST NATAL FOLLO VUP :
COMPLICATIONS OF PUERPARIUM :
(1) Puerparial sepsis
XXL
(Mother/Child)
(2) Mastitis
ANY SPECIAL POINTS ABOUT THE CASE :
(3) Thrombophelibits.
(4) Urinary infection.
FA-'ILY
I
NAME
(A)
II
HOUSING
A)
S)
C)
III
HEAD
THE
OF
OF
TH:_
FAMILY
PORTECTED WATER SUPPLY
TOILET FECILITIES
UNDERGROUND DRAINAGE
STATUS
SL.NO.
NAME
SC/
RECORD
r 00D
( C)
T/OTHERS
HA3jtS
VEG/NON
VEG.
CD)ADRESS
OF
FAMILY
P. T.
P . T.
PROVIDED
ATTACHED
CONNECTED
WELi
O.F.
OPEN
drain.
MEMBERS:
RELATIONSHIP
HEAD
OF
SEX
TO
MERITAL
STATUS
F.P.METHODS
IMMUNISATION
U.
•
W
C
■5 C G
IF MARRIED
F.P.METHOD
TM
DISEASES/CONDITIO NS
SL.NO.
HABITS:
V.
FOLLOW
SL.NO.
VI
(A)
PHYSICAL
D E F C R [■' IT Y
SMOKING
CD)
Ct)
CS)
ALEMXNTARY
CVS
RESPIRATORY
DRINKING
ALCOHOL
A
DRUG
SUSE
OF
ANY _ IRTh j/D.ATKG
DURING LaST ONE
YEAR
VISIT
0
(E)
(F)
GLANITS
URINARY
NERVOUS
SYSTEM
(G)
CH)
EAR
DEFECT
EYE
REPORT
0TH ERS
SPECIFY
CHEWING
TOBACCO
- IP.TH:
IF Y-S
XYESXNOX
XL -j:
\
TREATMENT.
S ' iOVATIONS
X ST ILL
X
DEATH .(A)
(B)
TT
D.T.
MEASLES.
POLIO
P. M .
UP
DATE
INFANTS
ADOPTED
FAMILY
N
IV.
STREET
H.NO.
SANITATION
AND
.
(B)
HEALTH
\< 1 YEARX
X MATERNAL
X
X
\> 1 YEAxX
DEATH!
X NO
(I)
TEETH i G U Pi
Cd'•’'i H I
BANGALORE
Mallur Health Co-operative,
DAIRY
Family Health Record
FORM NO.
Age:
Sex :
Name of head of the Family:
Member of co-operative :
SI.
No.
Wife and Children in Order of Birth
Relation
2
3
4
5
6
7
Health Conditions : Children Under Five Years
Health Condition of Others:
\
Yes / No:
1
.
J
\fc
Age
Sex
Occupation
Wage
SI.
No.
IMMUNIZATION
RECORD
OF
Name
Small Pox
B. C. G.
THE
FAMILY
T. A. B.
Polio
D. P. T.
1
2
3
4
5
6
7
8
9
10
11
111
SOCIO ECONOMIC
Income from • other sources:
Any Debt :
Savings:
Average monthly expense:
Housing:
Clothing ;
Food:
Social:
Education:
Transport:
Med. Treatment
Alcoholism/
Other
Miscellaneous:
Social Problems:
Casteism/
Smoking/
Nutrition & Diet habits:
Items in daily Diet:
Vegetarian
Non-Vegetarian
Deaths in family within 10 years with causes
Adequate
HOUSING
1.
&
ENVIRONMENT
By Car / Cycle / Walk
Approach to the house
2. Surroundings
Hygienic / Un-hygienic
Ponds I Pools of Dirty water / Garbage Dump I Manure Heap.
3.
Good / Fair / Dilapidated
Condition of the house :
4. Walls:
Bricks / Mud / Stone / Other type
Roof:
Tiled / Concrete / Thatched
6. Floor:
Earth / Concrete / Cow-dung
5.
7. Number of rooms
8. Air & Light:
Adequate / Inadequate
6. Number of windows:
10. Kitchen;
a) None (corner of the living room used as kitchen)
b) Separate: Inside the house / Outside
c)
Near the privy I Away from it
d) Smoky I Not smoky
11. House Refuse;
a) Thrown indiscriminately
b) Collected in covered receptacles and disposed off
into dust bin / manure pit / or by burning
12. Source of water supply:
13. Is the water boiled before drinking
Yes/No
14. Latrine;
a) Service type
b) Public latrine
c) Open space
15. Protective measure against:
Footwear used / Not used
a) Mosquitoes: Taken / Not taken
b) Flies;
Taken / Not taken
16. a) Any animals or poultry kept in the premises and their number
b) How the dung etc is disposed off
c) Construction of cowshed etc.
17. Any vegetable garden :
COMMENTS
Yes / No
Position: 2627 (2 views)