RF_COM_H_15_SUDHA_ PART 2.pdf
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RF_COM_H_15_SUDHA_ PART 2
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ANTENATAL CARD
'll
Save yourself and child from tetanus with
Tetanus Toxoid, one injection each month for
3 months Before delivery.
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anf tt stag r<a th,
tt T<fe srt srtfln T’l §1,
Name
W’dt <Rg
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feq Hint n h-7I?t a ar tnn Tt n't % g;qt th h th
'JT faga an tt h 1 an ar a f feal srinTt th thtt
at bht gfaf t! aga sr^l arg a gaar n 1
Name of Clinic
nit ana niar t! tprT Tt rare earn atgar
1 ga STTTT Tt aasft sir th ute gr tea th a
th ht frat aa (ai| ngl, rfte ar an frat at hh n
^ar nrFgrr 1 aFa gt ht at ht u^r €fa (ag an art
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^tit % ara Hi«r at t< nffe! Tt an? n Tat rg
Jgfr |, at at Tat sit3t*t1 hhis w alfirai stitt 5O
Vh HTat | 1
__________ -£^-
PREVIOUS
Duration of
Pregnancy
Number
PREGNANCIES
Abortion,
Stillbirth or
Died later or
Live and well
Delivery
Booster
3rd
Booster
nsa & nnn nrnnl ate
t! ante n fatr ?ht
ala bit (h(1h ngfe) nn a gl hththI t
nsani b1 nnus wu § mb as § aa’gs as!
an § 3 ala (hu18 hrIS) sag fea ui ssgi§ 1
Stenger Signs :
Special Care Needed
’rat Tt fasriHr
HBa al fsH’sl
rnrH rfinj
yrn famis aw
Anaemia :
as al an1
Hb under 9 Gms.
^h t! th!
Bleeding after previous deliveries or
during this pregnancy
MfUB ?B’ R’ feH 533 fewe’ M15
X*
Any baby born dead, or difficult
delivery, or forceps or Caesarean
operation ufuB aa m’UaHB B’H UB
U? R1 MU 31S US
—O—
Height............ ..........................
sai aa
glat t?
If under 147 cm or 58 inches
aran Sb wus s’aaa at rb’u a? i sag §u
ma feu 3H 3s feg aat aams si ansa 3’ ata 3 1
fea aia^ § na’afea e fagfa fag aS mb ae
ael nl 3hT fear@e bbI w@, ai £gi us e es w@
31 fea a’33 S few© 1 feu @s’ 5 m'uel aarl essm aas ks! aee aarn 1
Date_______ Date______ Date
•
2nd
and Hospital delivery advised.
fawnt n Tfeq, site an
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fenrsl 1 ng hhtt uittI n^st Ihhth t feq na?
tIti 1
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u'ute' 3 ua bb' el anal b sb mB ua aa we b1
ure faa fa’s efa (e'u, eut, sta a' ?n el nas fag
at 85' u'utei 3 : aaa u aa b’ tea mai ua aa
(feu araa sut’ ue) b ua§ faa e fas mat ate el
B5> giule’ 3 ajrl sa’a us a sieae el an! aala'
el na'a fag aal afu a’el 3 1 3 @u aal s’aea el
aniu S’B aialmi sia_ijul afal ai aael 3 1
Date
1st
nfiarar h th gfa t! narg
tit Tt "HlfteT t
an 31 a’e aet faaBatm’ § au’a r’ uaust wat
u R’e’ 3 1 Feas aaiat awa afaw r’ aaa’ 3 1 va
bb b ana (rub fsaBH’B aaa us sub Sail Bay
s’B ais 3s H’ul? us 1 @u a:at faae S’H sh a1
s’BW aas’ uS, Sait Bcj ^75 §31?? a a' tfai a @b
life 3~ lire fea fae araa aaa fae sw bx auifsw
^^aae’ 8 1 m3 saa ai e'st faas aa aasi u? @a
e an sat earl 3a’ a’s® s'B sHni bs aiute us 1
Date given
History
TB
Blood transfusion
Operations
Diabetes
other
Pelvis if small on internal
Swelling of hands or face, or diastolic
BP over 90
UW MU’ U’ ■RR3’
§15 ife Tt ffSTH
Breathlessness with heart murmur or
cough or sputum for 1 month
H’U 33/’ H’ uw fea Wils 3~ fawi
njg 5sar nr tsftat <it
a wt?r
4 children or more over age 35
4 aa a* fam’H' R' 35 h’b al
@hb
b1
Family History
TB
Twins
Diabetes
Other :
ua
sal:
____________ ___
Put a large X in the right hand
square for each danger sign
( X ) B’B faH'B e’ R3J55 3 UBBfel fsH’sl .
(x) vira fesrw ti HUH5 t
other
FNH-62
Tt ftesrpft
.
I
Last Menstrual period
O
Month
Day
Size of uterus
1
Blood
Piessure
Heart
Medicines diet and •
other advice
Symptoms and
Complaints
Family
Planning
advice
Pelvis or interna! Examination
—
z L.M
3
4
c
' tZ)
5
—
Movements
felt
-
head high
or engaged
Vertex breech
or transverse
Baby’s heart
now heard
—
-
—
—
--------- -----------
Come every 2 weeks
’nancy
1
since L.M
CLj
Come every weak
D u ratio n
o
£
00
In th is colum n fill in callendar m onth
i
ty ’s d ate w hen seen a t cl:inic
D ay oi th e m onth
Blood
Mb
Ccme monthly
—
£
Urine
albumen
t
Lungs
2
Wcicht and
edema
In primipara
head should
now fit into
Pelvis
1
If for hospital delivery
admit now
9
40 wk
Expected date of
delivery
Delivery
41 wk
42 wk
•
43 wk
44 wk
Date
On examination
J’ost Natal
Visits
■■/■TH CrU-
CO
irst .
;•
. ..oad
3ANGAl0k> r UUO UM 4
|
____________________
Krishan Sudama Press. Ferozepore Cantt.
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FAMILY
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IS EATING ALL FAMILY FOOD BY 18. MONTHS
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Banana
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Green Vegetable
Groundnut
CHILD HEALTH RECORD 0-6 YEARS
0-6 <Jii(nijL
L£ (5 sin £ til m ,
^(3ornriSuj
Date given
CLINIC figlsiflstrfiss
CHILDS No
©Lpji) fiD SjidUr
BCG against
GT GtjjJT
Smallpox
c3|LOSiDLO
Hospital Stamp
CHILD'S NAME @ Lp ri so)
id «rr Quujit
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TB
sseJI
5®UL|
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TAB
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firn urruj® ff(Hui|<9<rrr ffl
OTHER LOppOenaj
c^hGrirr
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MOTHER'S NAME
QuUJIT
-
____E___
OCCUPATION
U60W
FATHER’S NAME ^aGuSoflsST ©UU.IIT
tSlronj.®
MONTH
terr a>ib
YEAR
<nj(rF)L_ib
CASTE OR COMMUNITY
ffira;! <3>|Gt>suaj| LDa>ib
HOUSE NO.^LUJ.OT GT6OTT
TOWN
P.O. JJdblJLO
BIRTH NAMES OF
ORDER BROTHERS &
SISTERS
l51n)uq <fj&5>rr g>ij
curriers <3:(B.fhrr <9)irl
<3>gtH<ot
1
2
3
4
5
6
a.rruj jgiia,niTCT>i_ iSlsnrrtTOi^a e-snajuilsu roimtssja
Gia.ircnw Ssu«irai®ih.
Hie mother keeps this card in a strong plastic envelope.
Voluntary Health Association of India
C-14 Community Centre, S.D.A., New Delhi-16
7
8
Qljiuit
STREET/VILLAGE
^./rfrinib/pj^?
T ALUK £ rr Gyp a dS rr
©h
SEEN
yes/no
urijr?^
Age
GUUJgJ
DIST. g5]d)<Mrr
STATE OF
HEALTH
^Gijnra^liu
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i
1
1
1
1
1
1
■ 1
• 1
1
1
1
1
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HR—1 Tamil
psrr^l
Polio
other
inrrjpjfnQj
1
2
3
Mantoux
test
4
8
ucaert
n?euM
CHILD HEALTH RECORD 0-6 YEARS
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4H,<3ijrr&®w (jjjrQluq
Date given
CHILDS No
(SjJ^RjGIDfljAoT
clinic
GTGWT
1
2
3
Mantoux
teat
BCG agalnat TB
ictil f5®ui-| estifl
4
5
uGoen
result
Smallpox
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Polio ,
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Hospital Stamp
CHILD'S NAME @ lq ri;OT) 5u5!
TAB
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GiJUjrr
c2-h>Gnn- Quersr
•
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PgTtJJ
Other iflpnjCTXu
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MOTHER'S NAME
Quuj1t
OCCUPATION
UGWTl
‘
FATHER'S NAME gjauurafltOT GlulLlIT
|
YEAR
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HOUSE NO.Q$L_M
town
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CASTE OR COMMUNITY
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P.O. rpatrih
BIRTH NAMES OF
ORDER BROTHERS &
SISTERS
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surfles-^ tjGarr <srn
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STREET/VILLAGE
<5Birrrr tnLo/syj ifil
<5 tr gars a it
taluk
SEEN
dist. gijMiMrr
STATE OF
®®s yes/no HEALTH
unriscQ
Age
QlUJgJ
€(£)uorT
I
1
2
3
4
I
I
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i
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i
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6
I
I
7
i
i
I
attruj giasairriTstBL- i3smrCTUU).a> s_ct>njuSlsb smnjajgjtfi
QarrOTCTT S«U6tf5t®iii.
The. mother keeps this card in a strong plastic envelope.
Co-ordinating Agency for Health Planning
C-45 South Extension Part 2, New Delhi-110049.
8
S. I
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5
HR—1 TAMIL
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FAMILY
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REASONS
FOR
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io
11
10
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15.
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9.’
S<
3rd
YEAR
7*
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YEAR
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Pounds
2nd
4lh
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YEAR
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p; r. iprjinpij r vuajj
gjjHr«jjr® -1/ r,-y>IT5>|.=l1| I i.Sr lb LlilGV
<rr'(nj«Bioij ufreb
'.Lii^’3i.®'.b.
STARTING AT FOURTH MONTH, START FEEDING THESE FOODS IM ORDER SO THAT CHILD
IS EATING ALL FAMILY FOOD BY 18. MONTHS
1st YEAR
wifsj
0®fcu
dsig<£ffi6®Tl— :>.«ni.i| r,br (ip.wjnGuui®
ati>«jiSIgibu i'i u/djun® Glaiiiuic^ib.
.^niTlunr. 18 wn
(^uojjnir,
REASONS FOR SPECIAL CARE : IF SO PUT (X) IN RIGHT HAND BOX.
a
DATE
WRITE
GIVEN
HEALTH RECORD
FOR SCHOOL CHILDREN & ADULTS
CLINIC SoUc5
BCG
&
2
1
oo
3
BOOSTER
coJJ-3 h
EYES & EYE-SIGHT
£2.
vSdEElrt'Sb
RIGHT
LEFT
SMALL POX
NUMBER
EARS a HEARING
TETANUS TOXOID__
Cjcu'~'c33F'Oj'ud o^CiCj^cjO^
RIGHT
LEFT
BREATHLESSNESS WITH HEART MURMUR OR COUGH
OR SPUTUM FOR 1 MONTH.
PATIENT’S NAME cJSSfiCOC
CHOLERA
ADDICTION OR ALLERGY OR OBESITY.
WIFE/SON/ Cjjni.SSrt/TiSnS'd
DAUGHTER OF
CASTE OR COMMUNITY
Other
cjSo
OTHER REASONS FOR SPECIAL CARE
Other
■'““
' V
‘
•
Ci
Ct
’
FAMILY PLANNING
ARRANGEMENTS
g a s
TREATMENT
L
PROBLEMS
S ' DLI
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luC,
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SHOW THIS CARD TO THE DOCTOR EACH TIME,
ESPECIALLY AFTER ACCIDENT OR INJURY.
PROBLEMS
dl
““
zV
STREET
VILLAGE
TOWN PO.TEHSIL
sitlCKj sSra? t=.
d ^aJA?c5
TREATMENT
L<«.
FjO.
,<R.
HOUSE NO
S'-"'
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------------------------- ------------- 55
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HR4 KANNADA
Coordinating Agency for Health Planning,
C 45 South Extension. Part-2.New Delhi - 110049.
PROBLEMS
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gj30wvFiS?J
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PROBLEMS
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-
.
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WRITE DATE
2.7 J Couj ojOC3d_^
BCG*"
HEALTH RECORD
FOR SCHOOL CHILDREN & ADULTS
NUMBER ZiosJ.□
CLINIC 3o&Cs
£).
GIVEN
Di
2
I
3
BOOSTER
vj»soN/ eSo^/sSorS/sSirisfe
C^GHTER OF
RIGHT
LEFT
SMALL POX
EARS & HEARING
TETANUS TOXOID
c30“"0jvd OsjCCj^cjC^
RIGHT
LEFT
BREATHLESSNESS WITH HEART MURMUR OR COUGH
OR SPUTUM FOR 1 MONTH.
CHOLERA
^e)O03
CASTE OR COMMUNITY
'"■ j
So23-3 h
EYES A EYE-SIGHT
23.
TAB
PATIENT'S NAME &3?fiO5i Cu<Di
REASONS FOR SPECIAL CARE : IF SO PUT (X) IN RIGHT HAND BOX.
ADDICTION OR ALLERGY OR OBESITY.
Other
OTHER REASONS FOR SPECIAL CARE
Other
HOUSE NO sJOcSOjO nC.
TOWN P.O.TEHSIL
2s$oj<^ucj cid'c, s? ^joSj............
STREET
u3£,
SHOW THIS CARD TO THE DOCTOR EACH TIME,
ESPECIALLY AFTER ACCIDENT OR INJURY.
SusodiriVi
■
PROBLEMS
<
1
1
ARRANGEMENTS
TREATMENT
TREATMENT
rJ
PROBLEMS
^socSSrit'o
■?
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VILLAGE
cuc^Lrido............... cdocjonCL/Odo
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4^
-
—
HR4 KANNADA
Coordinating Agency for Health Planning.
C 45 South Extension, Part - 2, New Delhi - 110049.
_ - ----------
Bisao'o1
PROBLEMS
TMXTMENT
SicJc.’ 0 "sf
SLiV
F^BLEMS
gjaoddrisfo
TREATMENT
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COMM JNH'Y WCA'.
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47/iA‘iUJW^-7-------------------------------------------------------------------------
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Anti-T.B.
©.£>.£.
UNDER FIVES CLINIC
Clinic
o
cu0
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£oqjg
B. C. G.
£c&3S’e£5
1....................................
3&aj
2................................. :.
No.
Smallpox
?;a "t>Sb
C*3
Name
“i/£3&
~S&
iSs^aa
I....................................
M/F
«© 1>&
OQ^S "SJO5
Mother
Father
&r»a;6
SjJS'o sSs’ea
2.................................
£>oa sso&s
ro
ST’g&eo
|
2....................................
Triple D.P.T.
4....................................
3....................................
©5)iS3c$
Birthday
5....................................
—
-
|............
^©qBjo
&6&, £)§>, sjoiS c5oa&
Address
SJ’gS ©S^S-
2....................................
s^£>ew
3....................................
Polio—oral
4....................................
•................................ ■•
Siblings
aotoa^aa
SSX/
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SxftfrfMWo
sar’tfs'
T. A. B.
2..............................
3...................................
4...............................
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3a
Measles
i...........................
i
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5*«a§^o-aj, s^asj’tfra' &©aa.
D.P. MADRAS
REASONS FOR SPECIAL CARE
cOQoSs^Cf q$J0
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ST. JOHN'S MEDICAL COLLEGE HOSPITAL,
BANGALORE-560 034
THE JOHN McCORMACK HEALTH CENTRE
ANTENATAL/POSTNATAL INPATIENT CHART
NAME :
Hosp. No. :
HUSBAND'S NAME :
AGE :
Examination
Date
Complaint
General
Obstetric
Investigation
Progress
Treatment &
Remarks
5
v
LABOUR
RECORD
Time of onset of Labour
Date & Time of admission
Temp.
Pulse
Ht. of uterus
contractions
Tongue
B.P.
RS
CVS
presentation 8> position
Acetone
Urine & Alb.
Relation to Briin
Foetal Heart
Sugar
Membranes liquor
P V
Progress of Labour
Date
&
Time
Vaginal Examination
G.C.
Temp/
Pulse
B.P.
Contrac
tions
Memb.
F.H.
Dilatation of
cervix
Memb.
station
pres.
Drugs/Remarks
___ ___________
—____
___ _ ______
-
— —
OPERATION OR DELIVERY NOTES
Perinium Intact
Infant-sex
Alive/SB/DB
MRL 1-41
Temp.
Blood loss
Repaired by
Episiotomy
laceration
Summary—1st stage 2nd stage 3rd stage
Condition on transfer
from Labour ward
Condition
Mode of delivery
Placenta & Membranes—Wt.
Surgeon
Indication
Procedure
Date
Apgar
Total Durn
Pulse
Wt.
Durn. of RM
B.P.
Observation
Anaesthesia
Delivered by
Uterus
Baby
tU. cord
Mode of delivery
Remarks
NAME OE THE STATE—KARNATAKA
M.C.H. FORM
Corporation/Municipality/
Zila Parishad
Panchayat Union
1
DEPARTMENT OF HEALTH AND FAMILY PLANNING SERVICES
MPZTERWY RECORD
(Enter clinic vis ts in red ink and home visits in blue ink)
Card No.
Date of first contact
Name
Age
Parity
Occupation___________ ______ ____________ ______ ______________ ____________________
Address
__________________________________________
Husband’s name
Occupation
Family Income
Home: No. of rooms
No. ol occupants. Adults, Children under 14 year
Water supply
Latrines
PAST OBSTETRICS HISTORY
Pregnancy
Year of
delivery
Full terra
premature
Live
born
Still
born
Labour
Puerperium
Abor
Abnor Normal Abnor Normal
tion Normal
mal
mal
HISTORY OF PAST ILLNESSES
FAMILY PLANNING KNOWLEDGE AND PRACTICE
Abno
rmal
By whom Place of
attended delivery
_____________________________________
2
PRESENT PREGNANCY—GENERAL EXAMINATION
General Nutrition Vaginal discharge
Tongue
Teeth
_
He art
Lungs
_______ _________________________
Pyorrhoe a_________________________________ _
Anaemia
__
Cervical Glands
Breasts
N. System_________ _______________________
Liver
______________________________
Varicose veins
Bowels
Ext. Genitalia
I. C.
Spleen
_________ ________________________ .
Measurements-
I. S.
E. C.
T. R.
OBSTETRIC EXAMINATION.
L. M. P.
Urine
Date
Weight
Alb.
Sugar
Oedema
B. P.
Hb.
Ht. of
fundns :
Position
Foetal
heart
Presenta
tion
Initial
of
examiner
PROGRESS NOTES.
Date
Diet, Observations and complaints
Advice and treatment
"
——------
——----
___________________________________________________________________________
Laboratory tests, if any—
For Hospital/Home confinements
Booking arranged for.
3
HISTORY OF LABOUR
_______ _____ _
Place
Time Dr./midwife called
Temperature
Date
_ _____________
Patient’s condition----- ---------------------------Pulse--------------------- Reap.--------- --------- -— Urine
____—
Presentation
,
Position
Membranes-Intact
Engagement------------------- F- H.---------------Raptured when ?-------------- --------------- - -------------
Course of Labour:
Date
Time
Mother’s
pulse
F. H.
Date
Treatment
Uterine
Temperature contractions Engagement
Remarks
Results
Time
Enema given
Gatheterised
Vaginal examination
(reason)
Drugs given
SUMMARY 0 F LABOUR
Date
Hour
Minutes
Arrival of midwife
Length of 1st Stage ____________________
Commencement of Labour
Length of 2nd Stage____________________
Rupture Membranes
Birth of Baby
Length of 3rd Stage_____________________
Birth of placenta
Total duration____________ _____________
Placenta & Membranes complete
p p. H.
Perineum
Incomplete
Care given
Time of departure of midwife
__________
Condition of baby at birth alive/still born Macerated
Sex
Birth Weight
Congenital defects, if any------------ ------------------------------------------------------------------------------------Condition on departure of midwife/doctor-Mother
Baby
Mother delivered by
______________________________
Signature
4
PUERPERIUM
MOTHER.
1
2
3
4
5
6
7
8
9
10
Day/Date
Pulse
Tempera
ture
Lochia
Height of
fundus
Breasts
Bowels
Urine
Treatment
Bemarks
Eyes
Mouth
Cord
Stools
Urine
Feeds
Woight
B. P.
H. B.
Broast
Lactation
Uterus &
adnexae
General health
1.
2.
o.
4.
5
6.
7.
8.
fi.
10.
BAB¥.
Day
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
POST-NATAL RECORD.
Date
Urine
A
»
F. P. advice and Card No.
Infant Card No.
Signature
Card closed on
Health Visitor/Puhlic Health Nurse.
WD—45—PPP—1,0000'J Copies—14-8-74
____
____________
BSPT. OF COMMUNITY HEALTH
ST.JOHN'S MEPIO.iL COLLEGE, B.lNGALOHE
ANTENATAL CARD
Reg.No?
Date°
Names ..................... ......
Age;
Religions
Occupations
................
Occupation?
..........
....................
Husband's Name ?
..................
Family Income ?
Address?
................ per month
........................
Previous pregnancy & confinements ?
Number?
..........
Nature?
.
History of Lactation Period?
First
Present History?
Menstrual Cycle?
Last Menstrual Period?
................
Second
Others
2 :
General Medical Examination:
Oedema
Vitamin Deficiency:
Respiratory System:
Cardiovascular System :
Central Nervous System:
•thers:
Anaemia
RECORD
OF
PRESENT
Ht. of I.,, . .
Fundus We|9hl
Dale
Urine
Ooro H Ip 33
Tetanus
Toxoid
PREGNANCY
Oedema
i No ;
F. H.
PROBLEMS
AND
ADVICE
Folifor
tablets
Sign
I
Delivery Notes
□
Home
□
Hospital
INFANT
_ 1
Conduct by
□ Doc'or
□ Nurse
□ Dai/Trained Dai
□ Relatives
| Condition
Nature of Delivery
Normal
Complicated
Operation
□
□
□
F. P. Advice
FP Method Adopted
Preparing mother for delivery
General health care
Under 5 Advice
Immunisation
Weight in Kg,
Sex:
M/F
U/2 Registration No.
Infent feeding
Other
Card sent to CSU
Date
Signature
RUHSA
(K. v. KUPPAM BLOCK)
ANTENATAL
RECORD.
fiirtjfaiuwo utfQw®.
Previous Piegnancies :
gtriiiamn ujbfiuJ oSoipniiactr.
Year
Ramarks; Child's
Hoalth & Cevelopmon?
No
PiacS
Duration
Delivery
-------
.
Post Delivery
Complication
Sex
No:
Name :
QulUlt :
Husband's Name :
amroifr Outurr:
Address :
—
--------
—
—
—
—
Date of
Birth :
MC.
EDD
LMP
SPECIAL REVIEW:
Hb Bs'ow 9 Gms
a. ANAEMIA
After Previous Deliveries.
b. BLEEDING
During this or Previous Pregnane/
c. BLEEDING 1Baby Born Dead or Difficult Labour
d. DELIVERY
,Of Mother Over 30 or 4-th Child or
e FIRST BABY
Hb.
Hl
Condition of Nippla
BP.
HISTORY
&
Normal
More.
Oedema
GENERAL
P
G
A
Retracted
Lio
EXAMINATION
Priority StttUS
Z-
? 0
«
o
£ -■ §
Mor© than 4 children
Multi with few
living children
Priml above 30 years
Previous PET
Largs No. of Infant deaths
? s
Difficulties in previous deliveries
-j
■■ p 4
Bad obstetrical history
o
Provlous
PPH / APH
alth
Vt
M ac
Anemia
Poor Socio-economic status
PET
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Cl-
Wants sterilisation
Signature.
Date :
No special
problems
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(K. V. KUPPAM BLOCK) ANTENATAL RECORD.
Previous Pregnancies :
No.
'Si-
8?
s-®;
F ’s>
CS Si Si
8 3't
9i
<G
a
& S.
r §
b
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No :
Name
Quuua
Duration
Delivery
Post Delivery
Complications
Sex
Remarks : Child's
Health & Development
Husband's Name
&>GJmGua
Quuja
Address :
—
——
—
—
aS'cvas-ib :
—
——
•
| Caste :
Date of
Birth :
D
0
3
MC.
LMP
SPECIAL REVIEW :
a.
b.
c.
d.
e.
ANAEMIA :- Hb Below 9 Gms.
BLEEDING :- After Previous Deliveries.
BLEEDING :- During this or Previous Pregnancy
DELIVERY :- Baby Born Dead or Difficult Labour
FIRST BABY :- Of Mother Over 30 or 4-th Child or More.
Hb.
Ht.
BP.
G
EDD
-----------------------------.. ------ T.
P
L.
-
--------------------------------------------------------- Co
Reasons For Special Care
(N
r
Tetanus
RECORD
Date
OF PRESENT
Ht of
Fundus
Duration
Weight
BP
PREGNANCY
Toxoid
Urine
PROBLEMS
Oedema
j
u
-O
» i
'■
A?
-.’i.
1
1
■
Delivery Notes
INFANT
| Condition
Weight in Kg.
Sex:
1
M/F
F. P. Advice
Under 5 Advice
AND
ADVICE
C.O
H
I i . 3J
EDUCATIONAL GUIDANCE
EXPERIMENTAL BRANCH
Shankararah, P. 0. Tamhik, Dist. Midnapore.
CASE-HISTORY
A : Information Related to Pupils :—
IDENTIFYING DATA :
1.
(a)
Name of the child—
(b)
Date of birth —
(c)
Age—
(d)
Sex—
(e)
Name of the school —
(f)
Class —
(g)
Members of the family with relationship—
STATEMENT OF PROBLEM :
2.
(a)
Who refers the Case —
(b)
Nature of the behaviour disorder—
(c)
Disturbances—
(d)
Specific examples —
CONGENIAL FACTORS :
(a)
Insanity of parents—
(b)
Fickle mindedness—-
(c)
Epilepsy—
(cl)
Glandular disorder—
(e)
Alchoholism —
(f)
Nervous breakdown—
(g)
Instability—
(h)
Querness—
(i)
Querness in relatives & siblings—
PHYSICAL FACTORS ;
4.
(a)
Condition of mother during pregnency —
(b)
Nature of delivery—
(c)
History of birth injury—
(d)
Childhood disease—
(e)
Accidents—
(f)
Contraction of muscles—
(g)
Fainting—
(h)
Age of walking, talking and teething—
P. T. O,
[ 2 ]
ENVIRONMENTAL SITUATION :
5.
(i)
FATHER :
(a)
Experiences of childhood—
(b)
Education—
(c)
Occupation-
id)
Religion and personality traits—
(e)
Attitude towards wife and siblings—
(f)
Kind—Cruel—Sympathetic—Democratic—
(g)
Hobbies—
(h)
Recreational Interests—
(ii)
MOTHER :
(a)
Period of sucking—
Child’s behaviour to mother after or before
(b)
the birth of the next child—
(c)
Cause of abstaining from sucking—
(iii)
SIBLING INTER RELATIONSHIP :
(a)
Attitude towards each other —
(b)
Their health—
(c)
Undue quarreling—
(d)
Rivalry—
(e)
Schooling —
(f)
Present where abouts—
(iv)
PHYSICAL CONDITION AT HOME :
(a)
Physical condition after birth—
(b)
Change of residence—
(c)
Discipline—
(d)
Neatness and cleaness—
(e)
Arrangement of recreation—
(v)
METHODS OF CONTROL AND SUPERVISION-
(a)
Parents’ adverse attitude to child's discipline—
(b)
Nature of discipline ( by Reward or Punishment)—
(c)
Parents’ attitude to child’s discipline—
(d)
Any responsibility or duty of child at home—
(vi)
COMMUNITY AND CULTURAL FACTORS :
(a)
Culture in family—
(b)
Culture in neighbourers—
(c)
Any offence—
(d)
Financial status—
(e)
Social controls—
(f)
Recreational opportunities—
FACTORS:
(vii)
EDUCATIONAL
(a)
Age of entering school—
(b)
Subjects—
(c)
Attitude to Education—
(d)
Co-curricular Activities—
[ 3 ]
(e)
Evidence of leadership—
(f)
Rank in class—
(g)
Educational ambitions—
(viii)
RECREATIONAL FACTORS :
• (a)
Activities in leisure time—
(b)
Solitary or with group—
(c)
Whether liked / disliked / or abandoned by others—
(d)
Sign of leadership—
(e)
Membership in gangs or clubs—
6.
(if
REACTIONS IN EARLY CHILDHOOD :
(a)
Emotional reaction —
(b)
Signs of firmness—
(c)
Suspiciousness—
(d)
Thum sucking—
(e)
Fear reactions—
(f)
Sleep-walking —
(g)
Night-terror—
(h)
Love reaction—
(i)
Nail-biting—
(j)
If, accomodating—
(k)
If, quarrelsome —
(1)
Impatient—
(m)
Selfish—
(ii)
REACTIONS IN ADOLESCENCE :
(a)
Freedom of expressions —
(b)
Dependency on parents—
(.c)
If happy in group activity—
(d)
Dominant Recreational Activity —
(e)
Intelligence—
(f)
Personality—
(g)
Insight—
(h)
Attitude—
(i)
Treatment of the child ( after reports )—
B : Information Related to School—
(a)
Name of the Institution—
(b)
No. of students in the class—
(c)
Fees—
(d)
Teaching staff etc.
(e)
Distance from home—
t
P.
T. O.
COMMUNITY HEALTH CELL,
3"6, V Main. (Block
Ko,am: ng,3|0
Banga'c;c--560034
India
SCHOOL ATTAINMENT
NAME
F. L.
Yr.
|
S. L.
T. L.
...........................................................
M
|
P. s.
L. S.
TO.TAL
H
G
—
19
t
19
——
— —
—
•J
19
—— — —
—— —
—
19
19
- ---------- —
19
— — —
—
——
——
— — — — —
19
______ _i
Guardian’s Signature.
Counsellor’s Signature.
IMMUNIZATIONS AND PROPHYLACTIC DOSES
I.
II.
111.
WEANING
INDIAN COUNCIL OF MEDICAL RESEARCH
Small Pox
Primary: Birth to 3 months
Date
Re-vaccination : At the age of 3-5 years
and whenever there is exceptional risk
Date
...........
(GIRLS)
HYDERABAD-500007
CHILD HEALTH CARD
1.
Breastmilk is sufficient
3-4 months
from birth
to
1.
Between 2-3 years of age
2.
Date
At the age of 5 years
Household No.
Register No.
Child's Name
Triple Antigen (Diphtheria, Tetanus &
Whooping Cough)
Primary : From third month or even
earlier
Secondary: Two months after primary
injection
Date
Booster
Date of Birth
Date of first contact
2.
Date
IV.
NATIONAL INSTITUTE OF NUTRITION
Anti Tuberculosis (B.C.G.)
Primary: At birth or as soon as possible
Date
From about the 4th month, the child
is growing rapidly and breastmilk be
comes insufficient. Therefore introduce
some gruel such as 'Uggu" (rice with dal
and ghee) and continue breastmilk.
Father's Name
Occupation
Polio-Myelitis (Oral or Injectable Polivirin)
Date:
Mother's Name
First
Second
Occupation
Third
V.
VI.
Polivirin may be given in three
doses at monthly intervals start
ing from 3rd month or even
earlier.
Vitamin A Massive
Dose
Date
Dose
1
5
2
6
3
7
Siblings
Name
3.
Date
From the age of 6 months the breastmilk
supply diminishes and the child’s demand
increases. Therefore start some well
cooked rice with dal and soft green leafy
vegetables. Egg and milk can be given
if available. Continue breastfeeding as
long as possible. Give some biscuits also
which will help in teething.
Age
Sex
Remarks
2.
3.
4.
5.
4
8
6.
Note:
Vitamin A Massive may be given
at six—monthly intervals from
the age of one year.
7.
8.
9.
Others
Name
10.
Date
Doctor’s Remarks
4.
’ 'rsc(.;
’-'LTh
After one year the child needs much more
than breastmilk as shewill be walking
and talking. So give her rice, dal, vege
tables and roti in addition to breastmilk.
If available, egg, fish, milk and meat can
also be given.
COMMUNITY HEALTH CELL
47/1,(First FioorlS • Mar«cs r»oad
OC-S I H UJCO
Note:
■■■■■■■■■■■■■■■■■■■■■■■■
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,e IIIIIIIIIIIIIIIIIIIIIIH
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16 iiiiiiiiiiiiiiiiiiHsni
l5 iiiiiiiiiiiiiiiiiiiiiiii
cd
ob
£
IIIIIIIIIIIIIHIIIIIIIII
HiiiiiiiiBiiiiiiiiiiiii
14
miiiHiiiiiiiiiiiiiiii
iiiumiiiiiiiiiiiiiu?
13
uiiiiiiiiiiiiiiiisinii
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iiiiiiiiiiioinQnii
„ lllllliOfflSQnMiaffi»
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10 niiiiinu^
IIIIP iiiiiiiiiiiini
8 imiijiP
Weigh the child and make crossmark (X)
in the column corresponding to the ege
of the child.
I.
A mark 'X’ in the red colour indicates
that the child is healthy. If she is given
good food she will grow well and main
tain good health.
II.
A mark'X’ in the orange colour indicates
that she is underweight and she needs more
of good food to maintain good health.
III.
A cross markiin the deep yellow colour
shows that she is moderately undernouri
shed. Such a child must be given special
nutritious diet prepared at home.
IV.
A cross mark in light yellow colour
shows that the child is grossly under
nourished. Such a child must be taken
immediately to the doctor.
( 3-4 Years )
( 4-5 Years )
N. B : If a child has a moon face, oroedema
in the legs she must be taken to the
doctor.
<2 c m H / ^ - 2-8
k
SCHOOL HEALTH PROGRAMME
!%
'
CUMULATIVE HEALTH RECORD
Identification [riOUo&>]
CCiWMUNITY HEALTH CELL.
(Firs? F(oo;-)3t. Marks Road
BANG.Hcme - 5S0 00?
Teacher to fill up. [craKrep^asooo ioi3a5oi3^*>sb.]
Register/Admission No.
£>HcSci u* ate eB,?w
So
o
Grade/Class and Section
Pupil’s Name
Date of Birth or Age
Sota d sn&eaw e^'sra 5ajosi>
rit&F I TSort&f^^
as7>.®F
SSda
a ■
oi
Name and Address of
parent or guardian
Sod ©cter?
CM
Sex—Male/Fema.le
rtocSoySeao
Village:
School:
n-Sjdc,
Postal Address.
ecus awed.
HEALTH EDUCATION AND SCHOOL HEALTH SECTION.
DIRECTORATE OF HEALTH SERVICES BANGaLORE-9.
IMtsobb Statb]
INSTRUCTIONS
1.
This is a Cumulative Health Record of the pupil, designed to serve the entire educational
career of the pupil.
2.
This record to be transferred along with the T. C, to the next sehool.
3.
Records to be properly kept safe at the school.
4. To be filled up as follows :—
1. Cover page and page No. 1 to be filled in by teacher.
2. Growth Record on the inside back cover page to be written up by the teacher once
in 3 months.
3.
Second page of the record of (past history) to be filled up by the School Health
Assistant in the presence of parent or Guardian.
4. Back cover, outside information to be recorded by the School Health Assistant-.
5. Pagn No. 3 and 4, Medical Examination to be filled in by the examining Medical
Officer
6. Wherever a child iorefeired to P.H.C. or Hospital for examination or treatment
the pupil is to take the Cumulative Health Record with him/her.
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vScr
iocvna sjuaa aas^QAdoa aadrtea^ surrs
w^sSois'cJdnj
X
5
6.
S
6
a^oabiabaaai rajas”
'
<4*7
4 rfao sjurwaj*
°
ao^Soa
C3T—rcvcc; sc?gr» tf» u*S rt
es^rr^o 8^*3otrytt ^ospflra^ etjrt s*a** SxOj^Sj
W(JjS?r(
^oa.wsrtoe
*
entero
1
Name
Village.
School.
Date
a. Abnormal gait ea'as.as dart.
po^r posture rMidodd^ ■sa^o
Bleeding
b. Nose
sJjxrb
___________ J
Discharge
aow? sbca5jJEg>cto
C. Skin eruptions.
■
tSdjf- sra.O
t) ’_________
B ads too Cl< se
d. Eyes
c6a_caoD Lcotjsi
Defective
Beads t<»> t»r
Vision.
ctxoaod
cEtO
Sqmnt.
soxiaftco
dJin
Syle-.
1
1
1
Oc22) cObou
ra
Dehctive hearing.
ocvsaro^dj
Discharge.
e. Ear
ea
s3j^O.'ES)C1)
Mouth Br athrng
ifacroO crodoTdodida
Cracks at Corner.
saisrtva
f. Mouth
OT>»
I
Decayed Teeth.
rn.VoOl
” ’
Im £u;ar Teeth.
lullanieti longue.
eroc^saort.
Speech d. feet, stammering.
aetfSjaa; (aso:)
Shy
d’atio.
o
1
Ner\ oesness
g. Emotional
Condition.
©
h. Others
S23d
tjs. ac^ao.
Quarrelsome
t>n<?rtoU3rf
Co-opei alive.
ctSorFSO
A tit ndanue
3=at3O
>x<“,sSive us** of Toilet.
t3A"?rt
a0c2t3F”?sJ3^^o
n
-J
Code:— *^3. (a^E^cta*
No Defect
0.
Sjoodd^j^dja go.
Immediate Medical Attention
1.
i
1
—
rbdasarivo utfotoo.)
Corrected
4.
Under Treatment
«J ddaboa
|g} d
Tr.
saoadd;—
tjodj sjo
3o®jf e^Oj Soeg oaSjS.
Defect Requiring Altention
.... 2.
rtebaddes^o
Ir-remedial Defects.
SOdSiScrarid dJSjdd.
3.
Frequency : Atlea«t once a year
A. i
2
(To be filled up by the School Health Assistant in the presence of P^‘f^‘JS1Ga^dian^
(Zod JJfau
d^sodo
ed^ri, ^abiaJoddo dar
(A) PREVENTIVE TREA 'MENU AND TEST<BBFORE EACH MEDICAL EXAMINATION
t5^rada?j5?n'3a5o
I
(d,®
II
^:;08zi)________
ILL
History of Serum Reaction
djdite d:dia d,d.ofrtd
x S,a*,cSo
J ->
Primary
___
S mall-pox Vaccination
d;a;
J
Re.
did d$a
D. P. T.
Typhoid, Para-typhoid
as&ii^sfejd
Cholera
3203 t5?D
B. C. G.
2D, <\j. fco.
____________________________
Polio
CiSlS
Others
(B) HEALTHS HISTORY (o^C^ add)
!
Congenital Abnormalities
cisfdrtv;
Dalormities
Skeletal
4iOrt <230
a<i>Q <257>d
Polio
Tonsilitis
riouoo
Rheumatia Never
Measles
cics^cJ
Smallpox
<2dowo
Other Eruptive Fevers
Mumps
■33d ri.oa
tj.d
J
oj
°°t"
rsdriia^
Typhoid and Para-typhoid
—- ----------------------------------------------------eziSniSrWj
Accidents
Operatioi s
ad , ue>£
Worms
aSjaiS -oVo
Other Illness
Family History
o3
333 dj^rtrWo
Soujoud adoritfo.
3
(To be filled in by the Medical Officer)
III
II
1
EXAMINATION
Date.................
57>0(»i..................
^General Systemic Examination
, ...
1
Special Examination
(1) Vision
(a) Right Eye
(with & with nt spectacles)
(b) Left Eye
(with & without spectacles)
(2) Chronic Conju’-otivitis
Eyes:
o®S_
(1) Hearing Defect
(a) Right Ear
(b) Left Ear adaa
Ear 6®: ■<
(8) Chronic Otorrhoea
tocoioaoaod ed
NT
Nose
dxrarto
Throat
'(a) Special deviation
(aoodos3)djj
1 (b) Polypus
cl)
j
(c) Any other condition
gsc
■ •••
(a) Sore thro«t
rtoiaoj Serao£3
(b) Enlarged tonsils
oa^eraaiFG* jsdsj £>a‘rf
rtouo» ’ (0) Adenoids
oOiracOia^ (dejohdntfrt
)....
(d) Cleft palate
g s« idea4 (eorWj
(a) Carns
S.VJOOJ,
•
(b) Giugivhies
Teeth & Gum
CO tig -•
2c 03 oj3 8*3 cSfOCSO
(c) Malocclusion
3too‘eSj :$3’
(d) Pyorrhoea
SaSjs^oaJia
(e) Perbdonitiiis
j
4
Nutrition
Deficie
ncies.
ainsd doses’
a.
Anaemia
b.
Xerophthalmia
adj^sra^ccja
c.
BFott’s spots
III
II
I
au'w*. ?d? 13*
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d. Night blindness
37)ccbos7>cco
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c.
Superficial glossit:s
idjssjo6 4>e!iaho‘ rt^gis.u4
f.
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aoriOjCTao' sj^dja^gics;6
g.
Bleeding gums
dcsld?3C> Oct <\)
CO
d
•
Orthopaedic fefects
tDO 0 tOO rjJD.r5'Sjrt(>?0
Postural Defects
Mmtal Defects
#<e>
c*5yc)^c\)c '£>5c)0Cjc?
Speech Defects
djaSri'adod 3;acdd
•
Laboratory Findings
sjjcSz^rt B'adcco £U3 O3
c
II.
Medical Advice**
To the pupil
To the Teacher
crosroqre.cCaort
«
To the parent
E^/3£S$50n
>
Signature of Medical Officer
dgdtfd codo
Note
-of skin. Lymph glands, Alimentary sys'om, Respiratory system. Cardiovascular system, Nervous system
conditions like hydrocle, hernia, phimosis, enlarged spleen, liver etc. Please enter only the defect detected’
**To clearly mention theroieial services, if any, advise and fill up the refe a! intimation card.
tSair, it;wsror(, arpjSa'acrt, d.dco:od SodcOitd, dadiodo,
nxosdo
socdsTfanva^ cats
dgd^yadri
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and
GROWTH RECORD
€®WASD3
OSWALDS
5-s
57
Si
129-3
125’4
121’0
53
116’3
51
112107’8
103’4
99'0
4S
-17
4»
41
94’6
41
:->8
' 10’2
37
36
33
31
29
17
26
2S
21
19
Kgs.
M6’«
81’4
77’0
Weight -
150’0
147’5
145’0
142-5
140’0
137-5
135’0
132’5
13®’0
127’5
120
112-S
1200
117’6
115.0
112’5
110’0
107’5
105’0
102’5
100’0
Ozas.
so
«9
58
ST
56
65
64
\
53
1 5§
jd 61
* 5®
td 48
48
47
46
46
44
43
42
41
40
Inch.
72’6
68’2
63’8
59’4
55’0
50’6
46’2
41'8
Lhi.
Date/srao
Note-. Height f*5®,0)
Full line (3d)-------
Age/Sob^
Height/*1^,®
Weight/3^
Weight f&sS)
dotted (uSo’s*rt*52) .......
•stScfo
zttf <fi
trv*<3o <adcto
tfxotrari
ero*do oiTa^rt
(1) To be Recorded at every 3 months Interval
aJj* 3 Bo?WT4xo®®Giftr
(2) Both th<> graphs to be noted from left, sid> ■ onlv
<acWa
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I
1.
Small-pox
A&tU
2.
DAT
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1.
Specialist
2.
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as ei6$rt epc3
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CO £
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1.
School
sra«S
2.
Prv. Health Centre
1
I
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Sock
1
4
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’
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uJ _>
4.
IV
Follow up
slwcSoSorf
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qso stiri'pg
IV Foil- w up
ci. 0 C CjO 0 c*)i§
--------------------------- =>
WU t 06-58—uPB-i. 0,000 B.klts of U PP each—14-8-66
ni
ANNEXURE
IV.
DEPARTMENT, OF HEALTH SERVICES
SCHOOL HEALTH SURVEY
Name of the P. H. 0
Name of the village
Date of visit
...............................
Primary/Up-gradod Primary School
Type of Institution :
Staff:
District.
.................................
Number of Teachers
Popils:
Mon
Women
Total
Boys
Girls
Total
Working/not working
Betterment Committee:
Governraent/Private/rented/others
Building :
tiled/
Thatched/
Type of Roof :-
Mud/
Walls:
Stone/
mud/stone/RCC
Brick
Yes/No.
Whether white washed :
Mud/cow dung'washed/Cuddapa slab/Mortar/Cement
Flooring:
Square area:
Adequate/Inadequate
Window :
No.
Square area
Doors :
No.
Square area
Urinals:
No.
Latrine :
No.
Seating arrangements
Floor/Planks/Benches/Desk s
If desks are provided, whether they are of proper size
to suit the children-
Blaek Board :
Position proper or improper :
Water supply:
—
Play ground :
Type
Well/Tap/Otbers
How far is it from the school?
Yes/No.
Games played :
Indoor :
Outdoor :
Drill classes held
(Physical culture)
Yes /NoHow often?
Health subjects taught:
No ■ of periods per week :
Mid-day lunch programme :
Yes/No.
/
Type of lunch :
No. of beneficiaries :
Uniforms for pupils provided or insisted :
Yes/No.
Medical Inspection programme:
Yes/No.
If yes, how often ?
By whom?
Any First Aid facility in the school
[P.T.O.
Sara
(sbctc)
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WD P 0662—GPB—50 pads of 100 shts—25-8-66
ANNEXURE VI,
,
PRO FORMA
Depabtment of Poblic Health
School health Programme
MONTHLY PROGRESS REPORT
A.
General ;—
1.
Name of P. H. 0
2.
3.
Population of PHO (mid-year estimated
Population of schoolgoing age : (6-16 years)
4.
a) No. of Primary schools in the PHO
b) No. of schools selected
Medical Care —
'
Children examined by doctor
Children found defective
No. of Children followed up for defeats
Defects/deformity corrected
Spectacles/hearing aids supplied
No. of children
No. of children
School teacher sxamined
Immunisations ;—
Children vaccinated against Smallpox
Children given BCG Inoculation
Children given D. & T. Inoculation
1) Primary immunisation
2) Booster Dose
Children given T-A.B.
Children given other immunisation (specify)
D.
School Health Records ;—
Cumulative Health records opened
B.
School Health Instruction ;—
No. of teachers prepared for H. Instruction
No. oi local meetings (parents, teachers and others)
)
No- of schools visited by the Health workers
F.
Mid-day meals ;—
Schools with school lunch
G.
School Environment;—
(among the selected schools)
No- of schools with adequate safe drinking water
with sanitaiy latrines and urinals
No. oi schools having first aid kits
H.
Stock of Vaccine D 4T. :—
Stock at the commencement of the month
Received duiin-. the month
Total
Spent during the month
Balance on hand
.196
(Pri., Middle and High)
No. included
for tllli Vear
B
C.
fMonth of report,
Disttrict
Upto this
monih
During
<hia
month
.
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WD P 0661—GPB—5.000—17-9-1966.
DEPARTMENT OF HEALTH SERVICES
(School Health Section)
MEDICAL EXAMINATION
FOLLOW UP
Primary Health Centre
adia^rij
SCHOOL
WD P 0664—GBP—2,000 bks of 20 nhts. each—3-9-6b
SI. No.
Name of the Student
cn-3kJJ
ZSoKOi
rJO.
Reg. No
Admission No.
o&3,o’__ et^sls4
So.
i
i
i
Standard
Date of
Examination
Defects Noticed
250^^053
ooZ3icc3S S/tjSsS
Treatment or correction
advised
-j. CSZTcju S02CCSSO3
Result of follow up.
d»ode3t>=oj5onT>d afOSTior
S?3, SOco
D
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2
o<j
ANTI-TUBERCULOSIS IMMUNISATION (BCG)
Child's no.
Clinic
Child's name
Date of BCG immunisation
SMALLPOX IMMUNISATION
Boy/Girl
Registration No.
Mother's name
Date of immunisation
Date of scar inspection
Date of reimmunisation
Registration No.
Father's name
POLIOMYELITIS IMMUNISATION
Date of first immunisation
Date of second immunisation
Date first seen
Birthday-birthweight
Date of third immunisation
WHOOPING COUGH, TETANUS &
DIPHTHERIA IMMUNISATION
Where the family live: address
Date of first immunisation
Date of second immunisation
Date of third immunisation
BROTHERS AND SISTERS
Year of birth
Boy/Girl
Remarks
•e
0
•5 <*■
Date of immunisation
o
%
v-
MEASLES IMMUNISATION
i
'v
£
___________________________ si
OTHER IMMUNISATIONS
Cl
3“ 4 years
4°5 years
-
13
14
15
16
17
18
19
20
21
22
23
Upper Line: 50th centile Boys
J
!
;
‘
l>
8
9
10
11
1!
Lower Line: 3rd centile Girls
(International Children's Centre Study, U.K. Children)
I
Further information: TALC, Institute of Child Health,
London, WC1N IEH
24
Hospital
MATERNITY
(Stamp)
Name of Woman
F
fwNo-.
Ind. No.
RECORD
Gravida
Address.
.............................
W/o, D/o....................................................................................................
.....................
Head of household
........
Parity
...........
Normal
System
Date ...
Abnormal, specify
............| (2)
L. M. P............. VDRL
Rel. to Head .
Living .................
(1) Initial Physical Examination
Rh
Blood Group
E. D. C...........
Antenatal Record
Date
|
Wt.
Urine
Edema
B.P.
Sugar |
H.B.
Girth
Ht /
Fundus
Fetal
Heart
Position
Remarks / Recommendations
Exam, by
Alb.
Skin
Eyes
E.N.T.
Teeth
Neck
Heart
Lungs
Breasts
Liver
Spleen
Abdomen
Extremeties
Pelvic Exam.
.
General Physical
Condition :
F.S.A.P- Form 3
Past illnesses:
[ Please turn over
F. F. No
Ind.
No
(5) Delivery
(3) Dietary & Nutritional Status
Place:
Hospital
(6) Newborn
Live, born .
Home
Yes / No
By whom attended :
Type of Delivery .
Single / Multiple
Presentation :
Complications :
Male / Female
Maternity .
Birth-weight :
Summary of Labour:
Date
Arrival of N/ANM
Commencement of labour
Hour
Minute
Length of—
1 st stage :
2nd stage :
Rupture of Memb :
Birth of Baby :
Birth of Placenta .
3rd stage.
Total ...
CH Length :
H. C.
C. C.
Birth injuries :
Congenital Malformations :
Gen. Condition of baby :
(4) Pelvic
Measurement
Postpartum Physical Examination :
( Only for first F. T. Delivery )
Inter Spinous
Inter Cristal
Record filled by :
External Conjugate
Transverse at outlet
General Condition of Mother:
Date :
Checked by
Date :
Cc.r^ H (S'.X
NAME OE THE STATE—MYSORE
M.C.l-I. FORM
1
Corporation/Municipality/,
Zila Parishad
Panchayat Union
DEPARTMENT OF HEALTH AND FAMILY PLANNING SERVICES
MATERNITY RECORD
(Enter clinic visits in red ink and home visits in blue ink)
Card No.
-ac-eg?—________________ Date of first contact
Name
Occupation
Address
Age
_________________________________
_____
- z
Parity
______________________________________________________________________
Occupation
Family Income
No. of occupants. Adults, Children under 14 year
Husband's name
Home: No. of rooms
Water supply
Latrines
~————
PAST OBSTETRICS HISTORY
Pregnancy
Year of
delivery
Hull term
premature
Live
born
Still
born
Labour
Puerperium
Abor
tion Normal Abnor Normal Abnor Normal
mal
mal
HISTORY OF PAST ILLNESSES
FAMILY PLANNING KNOWLEDGE AND PRACTICE
Abno
rmal
By whom Place of
attended delivery
_____________________________________
9
PRESENT PREGNANCY—GENERAL EXAMINATION
Vaginal discharge------------------- -----------
General Nutrition___________________________
Tongue__________________________________ __
Teeth ____________________________________
Pyorrh oea____________ ._______________ ______
Anaemia_____________________________ _
Cervical Glands
_____________
Breasts
_________________ _
IIe a rt________________ _______ ._____________
Lungs--------------------- ---------------------------------N. System_________ ________________________
Liver______________________________________
Sple en___________ _________________________ .
M easur ements_____ _
Varicose veins_________________________ _____ _ I. C.________________________________ ____
Bowels___________________________ __ ______ I. S.____________ _ ________________________
E. C..______________________________________
Ext. Genitalia
T. R.
OBSTETRIC EXAMINATION.
L. M. P.
Uri no
Weight
Date
Oedema
Alb.
——
B. P.
Hb.
——
—
Ht. of
fundus
Position
Presenta
tion
Foetal
lies rt
—— —
—
r
—
PROGRESS NOTES.
■ Date
j
Diet, Observations and complaints
Advice and treatment
Laboratory tests, if any—
For Hospital/Home confinements
Booking arranged for.
Initial
of
examiner
HISTORY OF LABOUR
Place
Date
Patient’s condition
Time Dr./midwife called
Resp.
Temperature
Pulse
Presentation
Membranes-Intact
Position
Urine
Engagement
Raptured when ?
_
F. H.
Course of Labour:
----------
.
Mother’s
pulse
E. H.
Time
Date
Uterine
contractions Engagement
Temperature
Remarks
.
Time
Date
Treatment
Results
1
1
Enema given
Gatheterised
1
j
Vaginal examination
(reason)
Druss given
SUMMARY OF LABOUR
_______
Date
Hour
Minutes
;
Arrival of midwife
Length of 1st Stage____________________
Commencement of Labour
Length of 2nd Stage____________________
Rupture Membranes
Length of 3rd Stage_____________________
Birth of Baby
Birth of placenta
_ _ _________
Placenta & Membranes complete
P p. H.Perineum
Total duration
_________________ ,
IncompleteCare given
Time of departure of midwife ______________________________________________________
Condition of baby at birth alive/still born Macerated
Sex
Birth Weight
Congenital defects, if any
Condition on departure of midwife/doctor Motfer
_
Baby
Mother delivered by
Signa lure_______________ _________ _
4
PUERPERIUM
MOTHER.
1____________ 2__________ 3
Day/Date
|
■
4
5
6
Height of
fundus
Breasts
|
7
|
8
i
10
i
9
Pulse
Tempera
ture
Eyes
Mouth
Cord
Stools
Urine
Deeds
Weight
B. P.
H. B.
Breast
Lactation
Uterus &
adnexae
General health
Lochia
Bowels
Urine
Treatment
Remarks
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
BABY.
Day
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
POST-NATAL RECORD.
Date
Urine
F. P. advice and Card No.
Infant Card No.
Signature
Card closed on
Health Visitor/Public Health Nurse.
WD P05273—GPB—10,000 cards of 4 p.p. each
22-10-70
ALL INDIA INSTITUTE OF MEDICAL SCIENCES
(Centre for Community Medicine)
National Service Scheme
CHILD
IftWJCMSATIW' RECORD-
JHfei I'M? h ■■12-lh-^: Telbl m?. life
(}.2i&) libit ibh life
i-U®
—
ills ifaii h tllft &a .W= Jilh |lhi 12ih
('bJS ijte) -'£1^
£■
(W
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—
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Corn
I ST.
sdo9o
Government of Karnataka
M. 0. H. CARD
es&raer1
^ F/sciof
^Identification Data
ii rbdoSJba' arfdrt^o
i a #>&> siciS.
2 h rfcfrri/osracSoSo SXds
j I
2
Name of ANC/PNC
3 j rfcnX six*
J 3
Name of Husband
4 8 rtsJrrfoJj/KraraoSois snXXtf
4
Serial Number
Place of Residence
a. Name of Sub-centre
k a.
sxdi.’cc^d rfXdo
6 b.
519,03: dXd:
b. Name of Village
E c.
(1.
dcd5rt9 4,535 X:;3£
E3SX X,tid add
c. Couple Identity No.
d. Location of Residence
!
(
Within Service-centre area
1. txdasd Fj’cScS <;cd,c> «39/2,sb$
I.
2. wztasd wjciii i'.sdj s^rfjdd aJ.tdd. udd
arc,. e. Seed, d,d:dd^rt
2.
Outside Service-centre area; but within
PHC.
3.
Outside P.H.C. area
3. OT.e. a?cd, d,d:dd dJtdrt
5
eroadzyad ?KRtS ~ 3
j a.
Egofo aWth
Place of Service
a. Name of District
b. Name of P.H.C.
c. Name of Service-centre
h (Write name of Sub-centre and code
H number)
I
6
j
ro,. «. tfjod, 2. *^d wd.tert4 tleodjrtva
(P.H.U.L.F.D.^B) 3- txdSeodj 4. sfo-S.
7 ! twOoio/wdJttrt dcziirdoi) aS^da
Ovud O^" o^JvtJzS 7j*j. C-ii
Type of Service-centre
I. PHC 2. Other centres (PHU, LFD,
etc.) 3. Sub-centre 4. Home.
7
Name of ANM/LHV
$ 8
Phase of Registration
| 9
Age of ANC/PNC
9
ri$“ri/?53raoSoJ> doi)^
10
ri^)FriotocS^ os^da utoad suojtfa
Ante-Natal History
j 10 Date of ANC Registration
11
ask, aoritf rttprrf
J I I
Month of Pregnancy
12
tuSJOj £?£Jo33an K?.2;d sfc^Vo
I 12
Total number of live births
13
Sdj 2?5fc3wDA0:>3 rfo^va
34
w2SF?dw3A S>0l3jd
15
2uU3j'rt<!pF?53;wrt^ ^"•*■'5
aa!d
wrfrf
13
^0^
Total number of living children
| 14
Total number of Still births
* 15
Total number of Abortions
Post Natal History
J 6 | toiraoSafo?^ Otidjdo wjsad saOjiia
16
OcjtoS
17
ri-^rd
1. Cijdcd Xrirf
19
2. ciwFtd CJFJfJ
3.
•P
Result of Pregnancy
19
Type of Delivery
20
Neo-Natal Condition
21
Place of Delivery
d.
0:3
I.
I.
2-
1.
20
&SoM zSoxa
21
^ortolnd XQ 9
1. ^5~r :3vdrirt
2- °
I.
dVirfrt.
1. ZJ3,. U. tf.'Cuy 2. Sfc?!
4.
Date of PNC Registration
■ 17 • Date of Delivery
I.
3-
d5?aa?J.
rted.-t: ?
1. rt=3> 2.
?
dart ztoGCjESda
1.
2- ticLva
3.
eJ.d; HiU.oO 4. cdj^rt4 sJcSdri 5. C59O
22
rtipFdofca tied &3rt
ai/wASd ’i*
itdXoO. szoiaoia afcdfa^At^d
‘2’ £odo wdoicO.
■P.Z.S., Govt. Press. Bangalore.
24
3. Abortion
2, Abnormal
Full Term 2. Premature
PHC 2. Home 3. Other Hospitals
4. Private Nursing Home.
Male
'
2. Female
Delivery conducted by
I.
SD530 7. t^jvon1
otgJo 8. Xcwopidi.
6.
Normal
2. Stillbirth
Sex of the Child
I.
23
Livebirth
M.O. 2. L.M.O.
3. Other Hospital
staff 4. LHV 5. ANM 6. Trd. Dal
7. Untrd. Dai 8. Relatives.
If ANC is migrated to other
place code
If Maternal
death code ‘2*.
INFANT REVISITS
ssaesoi
Date
dotdouosi djaotddrW asdd
Observations & Complaints
Treatment
Name of Child
dododa tSXda
Name of Father
- ------
---------------------- ——————. ........................... ...................
-------------------- —
Give Special Attention to eyes. Mouth, cord. St
J
, Urine and feeds during neo-natal period.
rS)
H
£
o
V)
d/acri StSjaeqJtf OTStS’f I M MUNIZATION KECORD irfcSl aMtfo Name of the Child
djjtri
Immunizations
saOeiOa
Date
tita tdatfcId tijcfoa
SrfjJritUsr
Neo-Natal
3sO:sjo .
330’^3
Date
Date
P.V.
R.V.
djtfri
saOetdo
FjtJjtttfSri*
Date
Immuniza vj Ji tJ fj Cj5
tions
1st
sjsteoijst asterisk
Polio drops
D. P.T.
£>3JSdc5C33
cjJvCjDcjCjo ijdwcjCji
1st Dose 1 Ind Dose Hird Dose
a
djstri
adjtevdri*
Immuniza
tions
q^cs*
Typhoid
a.*.u.
Small Pox
Vaccination
sroOeiia
Date
ejdt3(3ojo
1 Ind
D &T
ijseJtza
Cholera
Bo osier Dose
B.C.G.
u
to. a>. a.
330e<53a
Date
Immunizations
dtO tdattoU z&cfcG)
330?iOo
Date
Neo-Natal
saOei):.
Date
'Jb.O.
P.V.
saOjiCo
Date
R.V.
Small Pox
Vaccination
Immuniza
tions
SDOfiOD
stiOeib
Date
Date
wJSCiOeJCjO
Cdt3(3oja
1st
llnd
djjsri
Immuniza
tions
a.i.u.
D. P.T.
Typhoid
—»----------3(seOo3uae ttocbriVo
Polio drops
tSTSCjOeidi adt&Joia
sixisdfSwo
1st Dose llnd Dose 11 Ird Dose
a tdoeb, t!
D &T
..........
Jjatfoa
Cholera
w
a. a>. a.
Bo osier Dose
B.C.G.
330;^
Date
j Super visor
djstrt adjsttptfrte
Sdtfo Name of the Child
dd sdn«)
iSxO.zsJd
«
3
Rem ark :s by the
draeri SdraeqJd oroofF IMMUNIZATION RECORD
s&M
tfeUrW aSd
Infant Revisits
aSricfc :....................................... Cort:............. tsSrtdDsaotf:..................
Name of the Child
Sex
Date of Birth
sjObtOfcd joc afc, sjaoaonw
Date
trcdtnd
Treatment
Observations & Complaints
oas.o*
dsttsd ddoci:
<J
Phase of Registration
ANC
NATAL
FNC
I INFANT
tiaort otts.o*' diaad cross
Date of First Registration!
T”
Serial No.
tu?,oi) taritb
uixcdeodj
Sub Centre and Village - .-------- ------------- --(Present Address)
- -
ssctoofc toJidj dodo, edr dadSri^ riojd4.......................
Mother’s Name & T. C. No
|
Isdsaa dotica Infant Death
QcSaotf Date :
sadra Cause :
* Give .special attention to eyes, mouth, cord, stools, urine aa^feeds during neo-natal period.
tdoflctod wotb Soritfddrt daristlri Srs^, tsacto, to.^S4<:, doodwadj
sarius osadci
at5?d risks iutaO,
dcdaitb,
Age at death :
~
5 Ora'r
ci
[/7
IMMUNIZATION RECORD
GROWTH CHART (I to 5 years)
INFANT REVISITS
Sirfd
shda
tfoc&wori Sjaoridritf arfd
Observations & Complaints
330C&X)
Date
Treatment
hdaarf tSrida
Name of Child
dodoJo tSrida
Name of Father
Date
trades
T.
Cause
rfoiado.
Age
♦Give Special Attention to eyes, Mouth, cord. Stools, Urine and feeds during neo-natal period.
Sex
hdoad
rfodts
Infant
Death
Com H
,W hr
|$.
If
hty
l—■
lr
£
to
ir
Itr
to- 4r Jr
Jr fp ifc
REASONS
FOR
SPECIAL CARE
B
L
kgs. ii -
—
IO-
kD
—
00
—
y
CT
—L
/
■z
/
/
5-
Z
.b
__________ L
THE BIRTH
'A/HIGH
1
</)
E
s'
>—
r
/
C
cr
■>
---
—
.
H AND YEAR IN THI S BOX
7ILY M ARKED
2_ LxJ
o X
M
s’ __
—
2 5 26 27 2 3 2 3 3 0 3
2-
1-
1'
1 1
7
*■
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1
1
3 11
1-
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1
51
’ Il 3 I' > 2 ) 2
J r
O'"'""®
0 1 ~O
GOOD
RISK
22 2 3 2 ’
J
DANGEROUS
3 2 3 3 3 4 35
J
B.L.-BORDER LINE
M -MALNOURISHED
ACTUAL WEIGHT CURVE SHOULD
BE PARALLEL TO THE LINE
BREAST FEEDING
__
SUPPLEMENTSIRON
__
DARAPRIM
FP
MOTHER
FATHER
I. WRITE MONTHS SEQUENTIALLY NEXT TO IT AND FILL THE CARD IN ALL MONTHLY BOXES.
2-NOTE THE MONTH OF FIRST VISIT.
WEIGH THE CHILD AND IDENTIFY THE WT. ON HORIZONTAL BAR
36. WRITE ANY ILLNESS IN PREVIOUS
PUT A DOT WHERE THE BOTH COLUMNS CROSS.
4MONTH IN APPROPRIATE VERTICAL
REPEAT THE STEPS 2,3,4 IN SUBSEQUENT VISITS AND CONNECT THE DOTS
5COLUMN.
MOTHERS LIFE RECORD, for serious illness, operations, children born
and family planning method used or present
MARKED WOMAN'S HEALTH EECOHD
(Explanatory fo’der available)
Year Ago Jan,Feb«Mar Apr,May-Jun Jul .AugiSep OctiNov«Dec No of children
Alive Now
Record only what is easily remembered
14
Health Centre
Number
16
together
menstrual
period
17
missed period
Name of woman
Husband's Name
18
abortion or
child born
dead
House Number
Street Number
Village
Tehsil or Taluk
15
19
child born
20
nursing mother
21
needs family
planning
22
Date
23
24
25
loop
26
27
28
29
30
31
33
34
37
CARE
eats
green
vege
tables
daily
put V
j.- vasectomy or
tubectomy
done
AFTER DELIV ERY
takes
if
if baby weigh
iron
mother small
baby—If
tablets has
or weak gaining
put y
daily
foul
or not
put y lochia sucking if not
gaining
or fever well
put X put X put X
-
(o) child died
-
-
•
Age at marriage
years before
oldest child born Next P regnanc y- - age of that child
now
add these to get
woman's age now
date
35
36
eats
extra
food
daily
put y
CARE
Date j Lips and
i
tongue red ,
or pale ?
BETWEEN
Problems
....
PREGNANCIES
Advice
38
2
39
40
41
42
43
44
© Voluntary Health Association of India
HR 12
Enfllish
C14. Safdarjang Development Area New Delhi-110016
SIMPLE HEALTH CARE DURING PREGNANCY
REGULAR CHECKS Put vz if answer is yes, X if no
GOOD DIET
Pregnancy number.................................
Date seen
'
Mother eats extra food daily
'
'
'
1
,
1
1
1
'
1
1
•
.
1
1
’
•
1
Pregnancy number................................
I
'
•
■
,
’
'
\
1
Mother eats green leafy vegetables daily
PREVENT
ANAEMIA
■
LipS ancj ;ongue red
.........
Takes iron tablets daily
PREVENT
TETANUS
and
FEVER
a{ter
DELIVERY
•
1
1
1
,
Sterile pack for delivery given
Knows to hold knife in fire before cutting cord
Trained worker who washes hands will do delivery
Clean room and clean clothes ready
'
....
Tetanus toxoid injection given (write date)
-
1
2
3
WATCH FOR DANGER SIGNS—if present put X
DANGER
OF FITS
Blood pressure diastolic over 90
Albumen in urine or finger swelling
DANGER OF
DIFFICULT
DELIVERY
^ead of baby not in correct position or baby's
head bigger than usual or could be twins _
Mother very short (Height less than 145 cm.)
Previous difficult delivery or dead
baby born, or delivery by operation
1st baby ; 4 children or more ; mother over 35.
1
OF BLEEDING tdeeding before or after previous deliveries
AT DELIVERY Bleeding in this pregnancy
,
'
1
1
'
1
''
1
|
'
'
:
’ll'
1
,
'
’
1
'
•
.
'
.
•
1
.
,
1
'
1
1
t
• *
'■
1 ‘
'
1
.
1
1
1
'
1
|
1
1
booster
'
1
'
'
-I--'-
,
1
■
Lips and tongue pale or very pale
OF HEART
OR LUNG
DISEASE
1
■
Breathlessness on walking
.......
Cough with sputum for 1 month or more
DECIDE PLACE OF DELIVERY
TREAT & ADVISE for Problems
With a V
,
home
Treatment
health centre
hospital
Problems
home
health centre
Treatment
hospital
CQrr)H
B’aoSo
1.
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1.
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4.
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2.
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3.
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6.
sacOjod: d?iil>............................................. 7.
9.
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ild. dedoSdand.d d.'S.Vj: rtodi
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......
a5d> |
300«30 ..
>■j ]
o
n •• 13
n V U
Re
12
T>
3 j o (J
a
s
£
eOjsrrtb
bdodd ewdssad (6 ssadrttfddrt)
8.
-—■°
a;j
T>
B
o _
"D
g
to'
y x>
M
-s
v •>
D
n
TO
g
e5D
B o
9
T3
§
a>
<0
TO
•C n3
13 u TO
TO
TO
(T
a n
a6
ID
Sdodri evdasad (ao& ddrd ddrt) a&dd^ OsS^dj djaQd sail
9.
t*jddox,d
~V; “■'"/
C53)333rS
Mrs;ra
10.
doittic add
twdowd
axacl.tf
«cv 3w, djj&Sj.
iddor. «sn>d.
u
-'
d
'adddrf tf:M d
add
°
, tWdrfrtofc afodrttf tertn rtsiorf fceao.
saoas eqina dsrbad dodra rtotfaXic^d add
L
saajol) d:dra dodty |
2.
42jdd cbdrs;
rt^rri
uod> ssddja^rt I
|
aSort
I
|
-jorsoa
1 • 4dadsii3«rt
d:drad ndra............ .......................... ....... ’,,............................
d-'dnd rcdci
4 asdd SoSd
1 ddrciatfrt
■«
C0rr\ H I V- irl
BOY or GIRL
iWn. 91 j
DEPARTMENT OF PUBLIC INSTRUCTION
(MEDICAL INSPECTION)
(1) Naina
!j>
(2) School
Address
(4) bate of Birth
Age
frevious history of:
Others
Small-pox
(at Standard
■8) Height
------
_
\)
ft.
u •
lbs.
9> Weight
(13) Ohest Mea f
TnBpr.
surement 1 Expiration
11) Skin
(12) Throat
(13) Nose
(6) Vaa'a
ft-lf^-jins. ,
If-O lbs.
■1Dins
ft.
1
ib»
ins.
lbs.
ins.
ins.
ins.
ins.
Diseases
Cleanliness
•!
H^arl
Body
ins.
lbs.
ins.
ft.
rnb.
lbs.
ins.
in?
—
..,—■————......
Arti- ul'O.ion
Tonsi's
Adenoids
1 Other Diseases
7
——-—
A'i4) Glands
(15) Teeth
Condition
Cari S8
Cleanliness
________
Other Conditions
Hearing } Rt.
at 20 ft. ( Lt,
(16) Ears
—------------------
Otitis Media
Other Conditions
Conjuno. & Lids
So uint
(17) Eyes
Vision
Rt.
Lt.
(p.i.a
2
(1) Congenital
(18) Deformity -
(2) Requited
(19) Nervous
System
_ _____
Paralysis
"
Epilepsy
(20) Heart and Circulation
—
'
(21) Anaemia
(22) Lungs
(23) Tuberculosis
(24) Nutrition
(25) Intestinal Worms .
-A ■
*
(26) Other Diseases
(27) General Intelligence
1
(28) Fitness for Drill and-games
(29) Directions to Parents,
Teacher c<r Nurse
-
"A
1
-
(30) Date anu M.O.’s Initials
Date
Notes o£ any previous illness, accident or operation and M.O.’s special
if any.
WD 634—GTBPM—3,000 pads of 100 shts. each—11-8-69.
report,
C tj rz) H I S'" I ■?>
FEEDING PROGRAMME
DEPARTMENT
INDIVIDUAL RECORD OF CHILD PERFORMANCE
sSoroaS etfjsem.spsS.a
crfo nafieS
a
D ©
Village
Taluk
Name of the Child
Age
District
Sex
cJtttOiSrJ cu-;^O
Ceti
Food items given and their quantities
Father’s Name
S.xUj asad
sot3 cSsdo
sSste ts
At Feeding Centre-
At Horae,
Occupation
Mother’s Name
sacoacda to&fo
Occupation
Monthly Income
£5uj<J0jD
No. of Children in the family
WEIGHT CHART
s-sod tew,
afoSctoedaai sJac.v Soi34
(To be recorded once in 2 months)
(OdcSo 3ori?rt»-ts3ofc
Age tS xbrio,
Months
■Son&rto
—
Year
cSSjF"
Date of
Recording
riodoc?xd
3aC;o3
Weight
(Kg-)
(«•«.)
Age
$32^3^
Months
ScrtorWo
Year
Date of
Recording
KiC'd'iXiCj
Weight
(Kg-)
djts
(S.tS.)
—— — — — — —
Immunization Chart
adjwsS
Small pox
siodoQ sJU
Age si 2*^
Months
Sondorisfa
Year
Date of
Recording
riodoa?.^
saOtSo
— ——
Polio
DPT
aiu
riidoSA)
I
^JtSoSja
i
2
3
3
Primary Vaccination
BCG
a^a
dtJj
Revaccination
Soda
OyA
Weight
(Kg.)
S/sS
(«-•)
NUTRITION
SCHEDULE
ASSESSMENT
(To be conducted twice in a year)
NOTE :
From item No
6 onwards, the investigator is to give a tick mark ( vz ) against
the item which is found present during the clinical Examination.
If the sign
is not present the column should be left blank.
Date of Examination................ .........
1.
2.
3.
4.
5.
6.
p
) 8.
Weight (Kgs.)
Height (Cms.)
Head circumference (Cms.)
Chest circumference (Cms )
Mid upperarm circumference (Cms.)
General Appearence :
ti) Normal bmlt
(ii) Thin built
'iii) Sickly
Eye fa; Conjunctive:
(i) Normal
(ii) Dry on exposure for
2 minutes
(iii) Dry and wrinkled
(iv)
Bitot’s Spot
(v)
Brown pigmentation
(vi) Angular conjunctivities
(vii) Pale Conjunctivae
(b.i Cornea :
(i) Normal
(ii)
Dry
(iii)
Hazy or opaque
Mouth (a; Lips :
(i)
Normal ■
(ii) Angular Stomotitis
(iii)
Cheilosis
(b) Tongue :
(i)
Normal
(ii)
Pale and Flabby
(iii)
Red and Raw
(iv)
Fissured
(v)
Geographic
(c) Gums :
Normal
Bleeding
■
1
y
r
I-
9.
10.
i
il.
12.
13.
Hair:
(i)
(ii)
(iii)
(iv)
(v)
Normal
Dull and Dry
Dyspigmented
Thin and Sparse
Easily Pluckable
(i)
Normal
Skin:
{I’i! Follicular Hyperkeratosis
Oedema: on dependparts
Rachitic Changes:
(i) Knock knees
or bow legs.
(ii) Epiphyseal Enlargement
(iii) Beading of the Ribs
Alimentary System :
(a) Stools :
(i) Normal
(ii) Diahorrea
(b) Liver :
(i)
Normal
(ii) Enlarged
NAME AND DESIGNATION
OF THE MEDICAL OFFICER
Special Instructions if any.
1
1
GROWTH CHART
LOCAL lieal™ WOMB
NOTE BOOK
^Wi
HTI
Area Served
.........................
Name of Worker...
—
_...•
Address of Worker...—
'RTT
Published by;
COORDINATING
AGENCY
FOR
HEALTH
C-45, South Extension Part 2
H. R. 23
NEW DELHI-110049.
PLANNING
REASONS FOR SPECIAL CARE
1.
Tuberculosis suspected, cough and sputum for 2 weeks
or more, or TB in family.
1 page.
2. TB started on treatment.
1 page.
3. Leprosy suspected or in the family.
2 pages.
4.
1 page.
Leprosy started on treatment.
Ulcers in leprosy need special care. Leprosy patients will
get less ulcers if special footwear is used, and education in
prevertion is given.
5.
Deaths with names, age and cause.
1 page.
6
Blind — so blind that they cannot work or count fingers
at 1 metre.
1 page.
7.
Malaria positive smears.
4 pages.
8.
Any other reason for special care in your area as decided
by doctor in charge.
9.
1 page.
Any other list the worker wants to keep; such as list of
those who have had vasectomy, a list of those who have had
tubectomy, a list of those using each family planning method.
1 page.
10.
Pregnancies and births to daughters-in-law of the village.
4 pages
11.
Pregnancies and births to daughters of the village.
*
Especially take care of any pregnant woman with :
Anaemia.
Bleeding after previous deliveries or during this pregnancy
or previous pregnancies.
Any baby born dead or difficult delivery or Caesarean or
operation.
Short stature (height less than 147 cm) or with small pelvis.
Or swelling of fingers or face or blood pressure over 90
diastolic.
Or breathlessness or cough or sputum.
Or first baby now expected.
Or age of mother over 35.
Or 4 children or more already.
Very thin or very poor.
12.
Mothers ( for family planning ) and pre-school children
Use many pages
Premature baby—2.0 kilograms ( 5 pounds ) or less when
first seen.
Breast milk stopped—before 3 months.
Weight not gaining - over a 3 months period.
Failure to add solid food—so far, and child now 9 months
of age or more.
Twins—especially if female.
Malnutrition—if second or third degree ( 11° or III ° )
Anaemia—( under 8 grams Haemoglobin)
Serious Disease—of mother or child, such
as paralysis,
tuberculosis, congenital defect needing operation, and also
low intelligence.
Mother or father dead—blind, mentally ill,
alcoholic
or
unemployed.
Three or more dead children—io. the family. Six or more
children in the family already. Children with white patches
on edges of eye.
( Vitamin A lacking ).
Reason for Special Care
qhq “t>l<ul
1
House
Number
2
Sireet
Number
35T
'Id 1
JTvft
-
3
Head of family
'JRSTR =PT fjfaRT
4
Name of Patient
fhft
-tht
5
Date
Special
care began
fa fa
fMfa
?far
-
i
6
Remarks
fWr
7
Jan.
SPTo
8
Feb.
TTc
10
9
Mar. April
11
May
’rrq- ?jsr?r
12
June
13
July
14
August
*1 ■‘Itrcl
15
Sept.
16
Oct.
17
Nov.
1
18
Dec.
T^rTo
■
.. .
-
-
Add up at end of each Month
HTH
sffc
Suggested abbreviations for use
local health workers.
Came to clinic.
if srnr I
Special care child came to clinic.
eztth 3TvTT
FHRT
if SJTTT I
Clinic visit due, but did not come.
%?g- snqi JTT Hff STTST I
Seen at home.
SR if
]
Special care child seen at home.
f^q- Etrnr
sr if aren ntTr i
Home visited, but child not seen.
SR
=RSfT Hff OT^T I
Needs family planning.
Getting extra food from us.
SffafkW Vf>5FT
if
| I
Kwashiorkor? ( swelling of body in young children )
Child is ill.
| I
Treatment taken in this month.
e^T vH I
Pregnant.
I
Baby due to be born in this month.
HTq if 5W3I
Operation done to prevent any more children.
3RTR I
Loop in position still.
5TH! 5Ffft FTTT ft | 1
Condom or nirodh or FL taken.
ffttrr
Oral contraceptive tablets taken.
fttvft ?ft ’if I
‘»nf
Tetanus toxoid given.
‘ftzTH &RTT^’
I
Triple vaccine given.
•feTvT ftafftH’ eft
I
BCG
Vaccine given against TB.
TAB
Vaccine given against typhoid.
S-l
Small pox given. ( first time )
S-2
Small pox given. ( not the first time )
afto <fto 3ft
I
ftfaft^TRT TT
I
3ft gt eft iff 3?- ?
ftXT 3ft
ift Tf 3>-^
1st. degree malnutrition growth curve climbing faster than
the printed lines on the weight record.
sntfir sr'si 3ft 5r<Fifca ftWr 3ft
EfSR Tft fttRT ft 5TTVT sra
t I
rt
fftTw, ?ft nf
2nd. degree malnutrition staying parallel to weight for age
lines on weight record.
fgafa w ?T 3ft sHtrf3ft rttert
% tsft qft
HHPdT t I
3rd. degree malnutrition getting worse - child’s weight not
keeping up with weight lines printed on the weight record.
aaftr ?T5T *pft smfccf
3ft tor HTHFtr HfF R?
<£>
Vitamin A deficiency.
fftzrfsH ‘IT’ 3ft T*ft I
f,
| I
C0 no Pi< S'
FEEDING PROGRAMME
DEPARTMENT
/
'
OF gffiig TKFHSE
t&rtos! edjsfrp.a^
a ato naajd
a 1 t) o
Village
iipName of the Child
siortjas ^-.c:
Food items given and their quantities
4,^ exad
recto ts
District
Sex
Cort
Father’s Name
Occupation
At Feeding Centre-
At Home,
Taluk
ZiS.
Age
Mother’s Name
sacOvOii tSdcfo
Occupation
8r.:u;
Month!/ Income
eorw1 snacda
Mo. of Children in the family
WEIGHT CHART
Svttfd s'4
^SofcgtfosS
xoii
(Io be recorded once in 2 months)
(£dc& SortSriJs^ ej?a rbdas*)
Age st
Months
SonthrWs
Year
Date of
Recording
riodaSJ®
330ju0
Weight
(Kg.)
3ja^
(«•«.)
Age S'
Year
Months
ocrWaritb
Date of
Recording
rtotfo-BAicS
sraostb
Weight
(Kg-)
3^3
($.£.)
Age S -tbjia,
Months
Sorferto
Year
aSr
Date of
Recording
riocbes.’d
saOeio
Weight
(Kg.)
(o.k)
•L-
Small pox
a
o
a
0°
O
C
H
.
e
>
•H
.
Cl
Immunization Chart
DPT
aw
1
Polio 1
cgj’tci.'a
tn ■
2
2
c *
3
3
c- ■
Primary Vacci-m.,
Revaccination
ssddo
BCG
1
e
c
c
c
o
•X'
O_
>
NUTRITION
ASSESSMENT
SCHEDULE
(To be conducted twice in a yeaM
NOTE :
From item No
6 onwards, the investigator is to give a tick mark (
the item which is found present during the clinical Examination.
) against
If the sign
is not present the column should be left blank.
Date of Examination ............................
1.
2.
3.
4.
5.
6.
7.
8.
Weight (Kgs.)
Height (Cms.)
Head circumference (Cms.)
Chest circumference (Cms )
Mid upperarm circumference (Cms.)
General Appearence :
(i) Normal built
(ii) Thin built
(iii) Sickly
Eye (a) Conjunctive:
(i)
Norma!
(ii)
Dry on exposure for
2 minutes
(iii)
Dry and wrinkled
(iv)
Bitot’s Spot
(v)
Brown pigmentation
(vi)
Angular conjunctivities
(vii)
Pale Conjunctivae
(b, Cornea :
(i)
Normal
(ii)
Dry
(iii)
Hazy or opaque
Mouth (a; Lips :
(i)
Normal
(ii)
Angular Stomotitis
(iii)
Cheilosis
(b) Tongue :
(i)
Normal
(ii)
Pale and Flabby
(iii)
Red and Raw
(iv)
Fissured
(v)
Geographic
(c) Gums :
Normal
Bleeding
—
9.
10.
k
II.
12.
13.
Hair:
(i)
(ii)
(iii)
(iv)
(v)
Norma!
Dull and Dry
Dyspigmented
Thin and Sparse
Easily Pluckable
(i)
Normal
(ii)
Dry and Scaly
Skin:
(iii) Follicular Hyperkeratosis
Oedema: on dependent parts
Rachitic Changes :
(i)
Knock knees
or bow legs.
(ii) Epiphyseal Enlargement
(iii) Beading of the Ribs
Alimentary System :
(a) Stools :
(i)
Normal
(ii) Diahorrea
(b) Liver :
(i)
Normal
(ii)
Enlarged
NAME AND DESIGNATION
OF THE MEDICAL OFFICER
Special Instructions if any.
GROWTH CHART
- - - ; I degree malnutrition
III degree malnutrition
ST. JOHN S MEDICAL COLLEGE HOSPITAL, BANGALORE
CHILD HEALTH RECORD
Com H I C- -3,g|
M-C.FL Form/^o.Ai.ooa5'. rfda-ad 2
siortoSJN esSuaerig csaaod
Card No/5^^s" Sc...........................
Date/£>Sicu...
(Enter clinic visits in red-ink and home
visits in blue ink/^Ss’a etoio
..............................
Village ,
S>f€> ersoSootooja Sda-raQS:)
saoiocdccjs £o;3 deiFis/rfa.
dc£j
Maternity Card No./^Oo sadcr So
Order of Birth/KSS £,do
C.iill’t 'Tin:/
dcdo&S dSdo.....................
............ Sex/®cri........................................ Date of Birth/^t^d Owtiou.........................................
Place of birth/cotii^'S
Ntturc of delivery/rabSoio 0?3
Attendant at birth/dOn Soddrcg
Sedoaoid ttdo.......................... Birth Weight/®-®^ dat^o, djan...................... Ante-natal Care/dt?Ftdojo Md.®...........................
Mother's Na me/st: dado coSda............................................ Occupation/«rodja.eri...........................Health/adaaeri.......................
Father’s Name/Sodo3a dSda............ .............................. Occupation/^vdat^eri........................... Health/t2t3ja?rf ... . ...
Address/^f S.................. —....... -......... -......... —...................................-........... —................ ..............................................................
......................
..Home/daS No. of rooms/<Lrad&iW Serf.
No- of occupants/dodoioidadtad
Soa34 : Adults/soacSdo
Children under 14years/14 daiofcdjas/ns zfootfo
Water supply
Seda SdtJcraKO....................................Latrines / SnSorttfo.................................... Cleanliness/i^darey...............................................
Type of Day care/d^ScGcj (cotleoo) yd^i§............................ .............................. Parents/*iit>ee^®da/Relatives/So2Jo^rWa,
Elder children/dOtda da® Va/Creche/iSodsrad
PROPHYLAXIS, a-raeri
IMMUNISATION/^-®^
:
I
Date/maos
Date/OS-soo
Date/^dtou
Date/Osrao®
Date/QStJoo
B.C-G./a.A.ti,
Smallpox/Ait^tco
D.P.T-/3-<2j.U.
Typhoid/£>=3dc te_d
V
Choi era/57Std7
Polimyelitis/Sddcot^OjaaOS
Others (specify) md (SQFs^ctm)
_____________ ______ __________ _
GROWTH DEVELOPMENT FEEDING/***^ JawsS, etsad
iI
-------------------------------------------------------- —----------
29
7
3
I
4
5S
66
77
8R
0
9“
10
11
12
Date of cxamination/dOtiSoto DwToS
^f^Kge of child/s^onOc-j^ EjOjOZjo^
....
Height/£>S.d
J*
Weight/Sirao
. .. .L O
rn m
> =' t>>
IT.
(S
.
1-- ... 1X1
- Q -i
"O r - - •
Holds head up/Sd SU.rt
Sits/^9^<ra^o s.d
-
Crawl s/:“«at?cd.d
Stands alone/«>oUo5jjh Ji^od.d
Walks alone/^o^o^9^ coCaOioos^Cj
....
Teethins/co?^ zjdo^doc^efo
....
Feeding Breast Milk/«5‘r3S-'
stcctiSoS.do^jCjo
Introduction of solids/St®, «™5dd edot^ ....
--j
«'• *lz»
g ?
0“£r
9 :f 0
£.£
Weaned/sSstseS W d
>
Feeds alone/^Ss
Sneaks words/£>Jt>ao udod.d
Bladder control/SjOcjad ujacd cOcxfoodjCa
Bowel Control/t/tJo^o Sojooo^ra
007-01-046
Date
Age
Diagnosis & Observations
3o3osb
37>0eil«
cJjaeri tdoeS isooo, etpn^oiori^o
]
I
Initial
Advance and follow up care
Sj7C^
So^Ej ?j2o
M.O./H.V.
sScra
as70 e.Juc.
d
t
WKS
GBDWTH
Between
green lines
tcsScia ueaJriAr
550 c5
Between
green & red lines
Normal 9O‘„ or above
ScoK (^?tSCo 90%
I degree malnutrition
^>s0j0
®
Uv&'JflV'
c«jOgj,
Eorfoj
coC^
CHART
Between
red lines
3o
o ? ri
sdocS
a
II degree malnutrition
Below
red lines
III degree malnutrition
uo^) deaScdo
ntf tp'sri
®
SjoOjO
e^uCoc^C go03>
(S^OjO uOcrrdfj coOS
© .
SNEHA BHAVAN EDUCAT'D )N AND HEALTH CENTRE
COMMUNITY
NUR SING
Age
Name________________
MATERNITY
RECORD
Cl. F. No. .
H. No.
Village
ANTE NATAL HIS•TORY
Previous pregnancies
Para
HEALTH
Present pregnancy Initial Physical
Type of Delivery-Alive / Dead / Abortion
1,
Date
Hb.
Rh.
2,
Blood group
L. M. P.
E. D7 C. ‘
3.
Skin
4.
Eyes
E. N. T.
6.
Teeth
7.
Heart
8.
Lungs
9.
Breasts
10.
Spleen
Previous illness
Abdomen
Extremities
Pelvic exam
Gen. Physical Cond.
Diet Excellent / Good / Fair / Poor)
^^^Date
Wt.
Urine
B. P.
Oede
ma
Girth
Ht/F
Posi
tion
F. H
Remarks- Recommendations
Exam.
by
/
___ _
---- ------------
r O O O .*'•*
m
•
r '.
ANTE NATAL - Continued
Date
Wt.
Urine
B.P.
Oedema
Girth I Ht/F ^Position
Remarks-Recommendations
F.H.
Exam.
by
DELIVERY & POST PARTUM
Delivery Summary
Hospital
Centre
Inst.
Normal
Presentation
Complications:
P. P. Physical Exam.
Weight'
Urine
Eyes
Lungs
Date
Sub-Centre
Oper.
Family Planning:
Home
P. P. Hemorr
Duration of labour
Date
~T. P. R.
Hb.
Attitude
Method accepted
Motive
General summary & recommendation
"
BP
. ..
Heart
____ ■-----
------------ -----------------------------
----------
Abdomen
Pelvic exam.
General condition
_____ _ ___ '■ _ ____________ —-—
Previous Treatment
Regularity
Months of Duration
,
I',
Concerning T.B.
TUBERCULOSIS , CLINIC CARD
(
(zk *ft.)
PAS
1.
sputum, but to save your life from this disease
This card is kept by the patient.
INH
44 4iii frft f qra
takes 18 months of regular treatment.
=4if^j i
INI-I-TZ
STM
Clinic
Number
s’ee
4o
2.
Sex
5EcE74lff44
Injector checks dose, and circles date of injection.
For correct
month, please compare with month column on inside of card, by
folding card inward to show X-Rays opposite.
M
©
Name
much more difficult to cure you.
F
3.
4.
We can help you prevent TB in your family.
51X7 4fX41X 4 ft .ft. ft 7741 414 flfsilT 1
4 4414 % ff
Date done
and whether
Chest
X-Ray or
Screening
or Mantoux
Name and
Relationship
414 sfir fT531
Result
47'414
7-ti
al.H7 aft 54 e
6.
7.
zft.sft. afe s
1.
arft^
f faq ^if ft 4§r 47? i
44i
f
h
4<t4 4i? §7
«na
§7 snar |
srtc 55THT (Sputum) ft w §7 sricfr | i tt, 18
4fift nu 55114 ^eiei 4stI 11
2.
4r4 414
Hl SW 4^'JT 41X7 % 414 5414 4’4
44 fl =ft4ift ftsr 4 ft
fh 44 sir st4>
4X41 444
X.
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 12 20 21 22 23 24 25 26 27 28 29 30 31
1 2 3 4 5 6 7 8 9 10 11 i2 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
fis 4444 sniq i h(1 4§i4
T.B. if untreated, or half treated, is a very dange
rous disease.
—O-
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
ei-ft 44i te surer
To take your treatment of INH, Streptomycin .or
PAS regularly, is even more important than a
good diet.
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 iu 20 21 22 23 24 26 26 27 28 29 30 31
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 2G 21 22 23 24 25 26 27 28 29 30 31
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Bring any child in your house who has cough, or
is thin and weak, and show to doctor. Bring any
older person who has fever, or loss of weight, or
cough.
Date of BCG if
Mantoux
Negative
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Burn it in
Use separate
spoons and cup.
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 11 19 20 21 22 23 24 75 26 27 28 29 30 31
\ 1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
1 2 8 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Do not spit on the floor.
ff.pfl fl. Tt ft4I 4441tf
1 2 3 4 5 6 7 8 9 10 11 12 13 11
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Keep a special container for sputum.
the fire.
5.
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Protect the rest of the family by bringing all
relatives to clinic for a check-up.
414
4X7 4^4 fl
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
If you stop treatment as soon as you feel better,
the disease will surely return, and then it will be
Other
STREPTOMYCIN INJECTION RECORD
It takes only a few months to stop fever and
§741 I
ft 414 e7.47. 45ftfti4> 4 4:44141
3.
sfwrix %
4^x7 11
4,
4444 f fair 5TvfTT 444 X4t I 451 4X 4 tpft 44§
47 H ’J fi) I 4444 (f MIX) ft 3T5TT ft I ^41 4§f 41X7
7 a74ix7 f 44I | i x7ft f 5?74i4 h trr7 4i7r 444
444 xft |
Protect yourself from other dangerous diseases
such as —
444 4I4t7 E4’7 44T41T 4141^47 4 44141 fft —
Date
Da te
r*ate
Date
5.
^44 (4’451 4t 4 4417)
Othc
E4T 574
414
tmrfr i 34 47 5i7<i7 fl xt 4i4 §7hi g^xl |
■541X 4ttHi 4i wftfr Xgrft | I
6.
4IT4 415ft l|XW 7 ft 34141 44lt <4T514 vHI 4|4
44X7 | I
Small pox
Tetanus ssag
sw7 44ftx, fix §44i 4144 x§7 414 4*47 ft
7.
e7 47. TI sm
at 7
4X§ 7 ^X1 551151 4§t ff4I 441
43X414 4741X1 <7 3441 t I 5441 H<7 JX1
5414 4^Xt | I
FNH-65
1
Months of
Regular
Treatment
begun
J
PAS
Tuberculin test
Day
Month
•/ear
HT5f
Sputum for
AFB. or,
biopsy
report
V» eight
(w)
Chest disease by stethoscope,
X-Ray or screening
Hb
and
ESR
Symptoms,
V " /
Other tests,
V /
Effects of
\[
Treatment,
Family Planning
advice and remarks
faSTlfaffr,
s.rat
Dose
How
often
tprq>
INH
Dose
How
often
fecfffr
INH and
Thiacetazone
Dose
How
often
Streptomycin
Dose
tpra?
ar?
No 0
Days
1
given
1 Next Visit
fefff
1 5ff?fr TIT
Supply
511
How
often
fcfHr
fffff
5R
57 nf
55lf
0
g-arf •1VSPK j')W
•>SU< oid iSJ WOO
s>1JC1A
pBOV
J.lNOV'
30 HA W3H
0
100 0-
\.
£ A
m
Date
i
2
— —— ——
—
—
3
2 4» f.
Date
5
6
.«
8
Date
9
10
1
11
12
13
Date
14
15
16
17
18
Date
1
,
Dosage in
children
Date of
pas 200 mg/Kg
100 mg/lb
Max 6 Gms
1NH 20 mg/Kg
10 mg/Kg
Max: 3<>0 mg
TZ
2 mg/Kg
1 mg/lb
start lowly
------------ 1-------------STM 40 mg/Kg
Max: 1 Gm
31'RTy
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NUMBER RTTTC
PATIENTS NAME
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AGE
CAST OR COMMUNITY
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WIFE/SON/DAUGHTEROF
Trffl'/fQTTT
cp H 1 LI
TOWN,P.O TEHSIL
STZ^SIdnLKdtrflei
HOUSE NO. L|chlH 4o
STREET Perft
VILLAGE J ltd
WRITE DATE GIVEN
#rrt rllilw
1
2
3
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BCG
.fiHSc^ch ch 1 d 1 <!4n I
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B.P etc.
rfirg', to,7t,
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EXTRA NOTES
& OTHER PROBLEMS
4^4 lil d chr2>-nX
TREATMENT
S.pi |O-I
STTeS- ent Ac-cdfrl <<3<l<d U-,<<-l 1 t; I
HR7 HINDI-ENGLISH
Voluntary Health Association of India,
C-14, Communit' Centre, S.D.A., New Delhi-16
t-i 2H1I
r3h#T
411 TOfJJ eti 1 lA'L'l 1 $4 1
<11 -did
drar tot tot#
SHOW THIS CARP TO DOCTOR EACH TIME, E SPECIALL'^^
£&sr accident or injury.
DATE
(use date stamp)
RIGHT
COMPLAINTS
LEFT
AND
DURATIONS
1st.
NO. OF VISIT
2nd.
ORD
4th.
1st.
3 RD.
2nd.
4th.
.UNAIDED
VISION/
WITH GLASSES
•
PROJECTION
OR
/Z />......
VISUAL FIELDS
'X\x^ ;
VISUAL AXIS
;
{
>
'}
\\ \
•• -'X^.
■ < J-T7
......... <•'.
PUPILLARY REACTION
TENSION
LIDS
LACRIMAL SAC
CONJUNCTIVA
,
< *
j>
CORNEA'
ANTERIOR CHAMBER
t
IRIS
<
LENS
r
X
*
MEDIA
■
X
“
' DISC
*
FUNDUS
*•
SV RATIO
l T'
;■*
DIAGNOSIS 1
2
‘3
.. •
4
BLOOD PRESSURE*
URINE
-
»
t
4
•
‘1 .
BLOODS OTHER TESTS
TREATMENT
1
OPERATIONS
9
GIVEN
3
•
-
4
5
ANY DRUG ALLERGY:
CLINI^TAFF CIRCLE ABNORMAL
W
FINDINGS
NEXT VISIT —^>
Copyright Reserved,
LEPROSy RECORD
Keep this card in a piastic covex. You must always take it
with you when you visit .- doctor, clinic or hospital.
^,r-z
?
-
£
jff erf ct cm! re c Facie R w i Fem rrmai-T,
ci? e't
€i
Tc? /in T'RCTT CI STIR mt tF?C *ltT Ttnt +1
4= «r nc mn t nil HRraiT Fttrih tri
snrnsm R smsr
t x? t stittr g'lm ?. i rtf:
met ct cut gam Rgt gtm mfaq i
Clinic
fteT
urns! mm ct ciRt r mcT /tn mT trit ci
tm«r m rmr Fem grfaciTc sm h Rgf emm
mFgq i st ma r Ttn Tgt ^tti cmr >fct sir
irtit gt 3irn =i i €tn at sm mt r -^m | i
Father
’tnt ct mn ft strt Tgm TtFgq ertFe
TgR c
eiftjr mr rrjr mt tttt ntr rrflT mr mm g
Ftrr c? gt ctar | i
?
ma ct gftcr rrr (RR RgR ana) mat r m ct
sAt RTgq m ct Tjr -Thm mfatr i cgt Rg'r
aha T fa<rt ana ci a? vgar | citit. fajt C SiTi
<n< eat shtir Tgt gt mm i njt met r cat
hr agt caat RiFgrr i
z
X
’tat ct qt men qgani mFgtr i an tt t?.r it
€ii ana tri me gtt ci st tri fgar g i
t,
naat ita R ght at cto CTat mFgq i <?t/s
riFhsi it th -tw gt arm | i Rts mfarsr R an
r na^m mat | iftT gm tI gta h era * i
jc? c Tint ct aam tth Tgm mFgn atr ?Bj
gaet era cam mfgQ i cm can h si/It e mil
4t wg aa Tga t i
\s
c
?
h-‘tt mrar srerT ct k'ma c Faq mrm hrt jt
ttt ma i? tit i
-----------------------------------
Number
Name
or Husba*»d
Age ^’5
fam CT TIR1
House No-
Street/Village
RT RiRT
nnt/mT
Town P.O.
Tehsil
TgRtR
sre^rm
•HISTORY
District
Fsfffr
OF THE DISEASE
»
Duration
First Symptoms
Recent Lesions
History of Contact
Previous Treatment
Other serious illnesses
PROGRESS SUMMARY
rrnfa RiTisr
TYPE
Indeterminate
Date Started
___________________________
qc CTT Ct fafa
a'tnt eWfm ntfec t/t (ma) mfgn i trc, tit,
asm am ?n>3 mfe wrt a ctf grFa ngt gtar,
«rfcc 3hh 5T?tT n^a gTit g i
Dates of Stay
fan 3t 5gt
Hospital
T
N
D
N? L
L
L
Reasons
CITC
atnt ct nntat mat ct ngt mrai mfgtr ant atm,
fante, nfai, maia, arm mmF? agt mat erfgq i
faefnar *fta
ata r ctf mam agt g i
-
gR mac rFtrit ct cna ftn am trFtc Ttn it
at. at. sft. mcr c mrr amm mga g i
No.
Name of Child
Dare of BCG
^=5^ if! •TfZT
Rt.Rt.5ft. CI RtCI
Became Inactive
Became Disease Arrested
Maintenance Dose
to
be
continued
.................................................................
for........................ years.
HR—5 HINDI
Coordinating Agency for Health Planning, C 45 South Extension,
Pnrt. ?
New Delhi. i tm^o
Other
(specify)
D.D.S.
co
c
Day
Month
Year
1
-X
Eye Drops
c
O
oa
ae
Times
per w<
Times
per w
Dose
mgs.
Condition
Skin
Smear
Month
c
Atropine
Z)
DATE
■j
d
ex
£
_ o
Ml
6
CC
A
M
physiotherap”
-
O
CO
rt
VI
a
o
Drug Allergy
(if any 1
ANAEMIA
CONTROL
Hb.
or
Pal for
Iron
OTHER TREATMENTS
pecif
NOSE
it meat
EYES
tr" ’MENT
3th er
ULCERS
,ANf)
ANT^fe •PROSY
(specify)
A
No. of
weeks
treat
ment
given
<3
2
3
1
4
5
6
*
7
■
8
9
10
11
12
13
14
15
16
17
18'
«
19
20
21
x
22
23
24
SuQ&estGd Dosage of D O. S.
Recommended I rcaiment for Reactions • In Order
i
2.
3
4
5.
N. B.
Rest - Aspirin - Alkalies
Aoti-mararial Drugs
Antimony - Course of Injections
B 663 - (Lamprene.
Corticosteroids (as a last resort.)
Check for ‘Other Diseases.
i mg.
IO mg
20 mg.
25 mg.
25 mg.
25 mg.
2/week x 4 weeks
2/week x 4 weeks
2/week x 4 weeks
3/week x 4 weeks
4/week x 4 weeks
daily or higher divided dose if needed
All Tuberculoid type patients require at least 3 years
regular treatment.
All Borderline and Lcpromatous patients require .at least
5 years regular treatment and are advised to continue Mainte
nance Dose for life.
Further records can be stapled on to this record.
PREVIOUS TREATMENT
REGULARITY
MONTHS OF CURATION
HEALTH RECORD
PAS
(LUNGS)
(nA I deft )
xUDU HI4^
1
chm-UI nt cfjTg
INH
INH - TZ
Zf
CLINIC
NUMBER
Hospital Stamp
STM
FfTK
OTHER
STREPTOMYCIN INJECTION RECORD
J-l1
1
et.cfr. (Wccp) h snt #
©
name
1.
AGE
FATHER/HUSBANO'S NAME
INJECTOR CHECKS DOSE AND CIRCLES DATE OF INJECTION. FOR CORRECT
chl
house no.
a STREET
Trfer VILLAGE/SUBURB
2.
BY
FOLDING CARD INWARD TO SHOW X-RAY OPPOSITE
I 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 2S 29 30 31
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 2 3 24 25 26 27 28 29 30 31
I 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 25 29 30 31
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 ?1 22 2 3 2 4 25 26 2 7 28 29 30 31
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 25 27 28 29 30 31
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
1 2 3 4 5 6 7 8 9 10 II 12 13 14
15 16 17 J 8 19 20 21 22 23 24 25 26 27 28 29 30 31
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
1 2 3 4 5 6 7 8 9 10 II 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
1 2 3 4 5 6 7 8 9 10 It 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 2 7 28 29 30 31
-r ^-4 ct kA TT
I
faf, s—
XgQToPi A)ch cFrJ sVR |o? 44 Tel faj cfft 4-ofckQTJ
TOT gt
Tfhrl -clct-eh-l rfmT
dlc*r‘U<
town.
<qq 3TTCT c£?l 4-1 d IM d I cHT xHcVirf et I
cR
NAME & RELATIONSHIP
(OF CONTACTS)
•m ArnftirciT
((CUtciA xtt fSmiife
<3419414
Weft
DATE DONE & RESULT
<41 Z1<A 3“iT <4ra
tslcfi cFTT
MANTOUX | jtrftcFi
SCREENING
SPUTUM
QjcJn
PROTECT YOURSELF FROM OTHER DANGEROUS DISEASES SUCH AS :
3Tn4 ent gg- f^hjp-icFi ^qrfert' £r mft
c\, ,
ci i Qi
SMALL POX
TETANUS
cfi XT IM4 3mt'Ta’®'<TT
cptt^ h
h 7-mr
Voluntary Health Association of India
C-14 Community Centre, S.D.A., New Delhi-16
rl£4l“feT TEHSIL/TALUK
p.o.
TYPrtOlP
t=n
CHOLERA
..
-i-
•• c
rIKKa
ex.
ett<t
5TTT (I JSH 3UT
mm |
sfk mm (Sputum) m qnr ^t srraY 11 it, 18
TT ^rtl3f mum mmU 1
3nT l^chld
MONTH. PLEASE COMPARE WITH MONTH COLUMN ON INSIDE OF CARD
V4T 5JT
ex
ufa JHT
HT TT^T
TTm T m? TT'DT Tm
mt at mmfr fax a ^t munt sftx tt u?r ata;
rpxm a|a afca <tm i
3. qfxmx mr mm qft ma st.af. mftfaT R Txmm
mm r | i
4. mat
tx fra xmT i mrnnr t fmr srarr aaa
Tnt i crt <rx a ?rat m? xx a ^at i mxmr (tmmx)
at arm at i
ngt nrra a atunt forat | i mm t?
3Tama t sna ata aaa Tian xt i
5. Tian wilx, wtx ffam nrrat x^h m^ mmi nt aim
mxmm i an as mm nt nt aim gtm amt |,
mmx mi ar nma'nt x^ft | i
6. maa mat main? a nt smm amf
am aga
amt f i
7. atari, an am aa<r arg a 'jxt farm
fnmr mrr
at
trnr imrxmr mmxt §t amat |1 aaar mt
<jxt ^nna- anxt | i
Concerning T.B.
1. It takes only a few months to stop fever and
sputum, but to save your life from this
disease takes. 18months of regular treatment.
2. If you stop treatment as soon as you feel
better, the disease will surely return and
then it will be much more difficult to cure
you.
3. Protect the rest of the family by bringing all
relatives to clinic for a check-up.
4. Cover your mouth when you have a cough.
Keep a special container for sputum. Burn
it in the fire. Do not spit, on the floor. Use
separate spoons and cup.
5. Bring any child in your house who has
cough, or is thin and weak, and show
to Doctor. Bring any older person who has
fever, or loss of weight, or cough.
6. To take your treatment of INH, Streptomycin
or PAS regularly, is even more important
than a good diet.
7. T.B. if untreated, or half treated, is a very
dangerous disease.
DATE i RESULT
t aft
BCG
Mantoux
rlQ ficb
chf <f]cfi 1
SJR V
J UT.Chest isease by
stetho scope.
X-Ray or screening
<s
PAS^
r
<1
i<
Sputum tor
AFB. or
biopsy
report
t
i’ojC/iL'
f5
Ik'S
hkrt
WT
Day
Month
Year
.. c
fasnfad, s*nsr
*TR.
ESR Weight
Symptoms, Other tests,
Effects of Treatment,
and remarks
Hb
INH and
Streptomycin
Thiacetazone
I^T^t
'•(I’J?
(XR) pitfall*
'z
INH .
cJirt-fi <c|t Idr1 encl'll
3TT
sTR
How Doso How
often
often
4/
‘A/
Dose
salt’
Qrrf
IQlrtHI
<snr
gTFT
Dose How Dose
often
•Az
STT^ “HTt
T3f2r
2^
Date of
Other
No. of
Treatment and Days
Hoy/
Family
Supply
often
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15
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17
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PAS ?oo mg/kg
inh 20mg/kg
TZ 2 mg/kg
I0omg/|b
MAX :6 GMS
10 mg / lb
max . aoomg
l mg/lb
START SLOWLY
dosage in
.
DRUG ALLERGY:
HR3
CHILDREN
HINDI-ENGLISH
STM 40mg/kg
MAX : 1 GM
Copyright Reserved
Concerning T. B.
HEALTH
RECORD
It takes only a few months to stop fever and sputum, but to
save your life from this disease cakes 18 months of regular
treatment.
If you stop treatment as soon as you teel better, the disease
will surely return and then it will be much more difficult to
cure you.
Protect the rest of the family by bringing all relatives co clime
for a check-up.
Cover your mouth when you have a cough. Keep a special
container for sputum. Burn it in the fire. Do not spit on the
floor. Use separate spoons and cup.
Bring any child in your house who has cough, or is thin and
weak, and show co Doctor. Bring any older person who has
fever, or loss of weight, or cough.
To take your treatment of INH, Streptomycin or PAS regularly.
Is even more important than a good diet.
T. B. is untreated, or half treated, is a very dangerous disease.
I.
(lungs)
2.
kindly bring this card to hospital each time
Clinic
NUMBER
3.
4.
5.
STREPTOMYCIN
INJECTION
record
father/husban-d'-s
6.
INjeCTOG CHECKS pose AND CIRCLES DATE OF i.nJjECT»ON • FOB CORRECT
MONTH
Pl£A6E COMPARE WTH MONTH COLUmM ON INSIDE OP CAfcp, Sy
Folding card inward
to
Show
house no
& Street
7.
x-RAy opposite
sot ir
1.
I 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
1 ? 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
2.
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 47 18 19 20 21 22 23 24 25 26 2? 2$ 29 30 31
1
2 3
I
2 3 4
16 17 18
4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
15
WE
CAN HELP you
3.
1
NAME & RELATIONSHIP
6
date done & RESULT
£op contacts)
8 9 10 11 12 13 14
19 20 21 22 23 24 25 26 27 28 29 30 31
5
PREVENT THIS DISEASE IN YOUR Family
7
CHEST
X-RAY
Screening
SPutum
4.
MANTOUX
B.C.G.
==
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1 2 3 4 5 6 7 8 9 10 11 12 13 14
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