A PRACTICAL NOTEBOOK

ON

FAMILY HEALTH CARE

Name:

University roll no:

Batch :

Department of Community Medicine

INSTITUTE OF POST GRADUATE MEDICAL EDUCATION &
RESEARCH, KOLKATA

West Bengal University of Health Sciences

 Certificate

This is to certify that Mr/Ms .……………………………………………………

Roll ……… of batch …………………….. has completed his / her Family health

care services satisfactorily

Signature of the Teacher in charge Signature of the Head of the Dept.

Community Medicine

IPGME&R, KOLKATA
 CONTENTS

Topic Page no

1. Introduction 1

2. Objective 3

3. Methodology 3

4. Geographical Map of the Community 4

5. Family: Identification and particulars 5

6. Housing & environmental condition 7

7. Socio-economic characteristics and socio- 10

cultural factors

8. Health status of individual family member 12

9. Health check-up of Under Five children 18

10. Maternity record 33

11. Health knowledge of the family 35

12. Nutritional profile of the family 39

13. Summary 43

14. Family diagnosis 45

15. Actions taken 45

16. Recommendation 46

17. Acknowledgement and Bibliography 47

1. Introduction:

Page | 1
Page | 2
2. Objectives:

3. Methodology:

Page | 3
4. Geographical map of the community:

Page | 4
 5. Family Identification and particulars:
Name of Head of Family (HoF): ……………………………………………………………. Address: ……………………………………………………………………………………………

Type of Family: Nuclear / Joint Religion: ………………………… Caste: General / OBC / SC / ST

Mother tongue: …………………………………. Length of Stay: …………………………………. State of Origin: …………………………….

Family composition:

Sl no Name Age Sex Relation Marital Education Occupation Income Nature

with HoF status (Rs / of work
month)

Page | 5
Total number of family members Male: ………. Female: …………
Number of infants (0 – 1 year) Male: ………. Female: …………
Number of 1 – 5 yr old children Male: ………. Female: …………
Number of adolescents (10 – 19 years) Male: ………. Female: …………
Number of geriatric persons (≥ 60 years) Male: ………. Female: …………
Number of pregnant women
Number of lactating mothers

Family tree:

Page | 6
 6. HOUSING AND ENVIRONMENTAL CONDITION:
PLAN OF THE HOUSE (SCHEMATIC DIAGRAM)

A. Housing
Type of house: Kuchcha / Pukka / Mixed
Ownership of house: Owned / Rented / Shared
Numbers of living rooms / bedrooms:
Area of other space utilized for living purpose: ……………………….
Total area of the space utilized for living purpose (in sq ft) : …………..
Overcrowding:

Comment on
Criteria Room 1 Room 2
overcrowding
Per capita floor space
Person per room
Sex separation

Lighting: adequate / inadequate

Page | 7
Ventilation: adequate / inadequate Cross ventilation: present / absent

Dampness: present / absent

Kitchen: in separate room / in living room / in verandah

Smoke outlet in kitchen: present / absent

Types of fuel used: wood / coal / kerosene / LPG / others (specify) ..................

Whether pets are kept: yes / no In living room? yes / no

B. Water supply

Source of water:

• Water for Drinking:

• Water for Cooking:

• Water for cleaning / bathing / washing:

Distance of drinking water source from the house:

Mode of supply: Intermittent / Continuous

Storage of water: Covered / Uncovered / Narrow mouthed / Wide mouthed

Method of drawing drinking water from the storage container: Safe / Unsafe

C. Excreta Disposal

Sanitary Latrine present? yes / no

Used by : Family members / Community

Location: Within premises / Outside premises

If community latrine

Distance from water source:

No. of users
Flushing facilities: Present / Absent

Water supply for flushing: Adequate / Inadequate

Cleaning done: Daily / Weekly / Occasionally

Excreta disposal of under five:

Page | 8
D. Refuse disposal

Method of

a. solid waste disposal:

b. kitchen waste disposal:

Fly nuisance: Present / absent

Breeding places of mosquitoes: Present (specify below) / Absent

Page | 9
7A. SOCIO-ECONOMIC CHARACTERISTICS
Total family income per month: ......................

Per-capita monthly income of the family: ..........................

Modern amenities present in the family:

Expenditure break-up of the family (Rs)

Food:
Fuel:
Rent:
Education:
Health:
Electricity:
Debt payments, if any:
Addiction:
Miscellaneous (clothing, recreation etc.):
Total:
Income and expenditure: Balanced / Saving / Deficit ........................

Pie diagram showing monthly expenditure pattern of the family:

Page | 10
Socio-economic Status (as per modified Kuppuswamy scale, updated 2018):

Criteria Status Score

Education of HoF

Occupation of HoF

Family income per month

Total

Socio-economic status:

7B. Socio-cultural problems in the family:

Page | 11
8. HEALTH STATUS OF INDIVIDUAL FAMILY MEMBERS (age above five years)
Sl. No ………… Date of examination: …………………………

Name : ……………………………………… Age: ……… Sex: ………..

History of present illness:

History of past illness:

Personal history:

Menstrual history:

General Examination:

Height (cm) Weight (kg) BMI Pulse

(kg/m2) (/min)
BP (mm Hg) Pallor Cyanosis Jaundice

Clubbing Oedema Neck Neck

glands veins
Tongue / Eye / Ear Any
Teeth / other
gum findings

Systemic examination:

Cardio-vascular Central Nervous

System

Respiratory Genito-urinary

Gastro-intestinal

Laboratory Findings:

Provisional Diagnosis:

Management:

Page | 12
8. HEALTH STATUS OF INDIVIDUAL FAMILY MEMBERS (age above five years)
Sl. No ………… Date of examination: …………………………

Name : ……………………………………… Age: ……… Sex: ………..

History of present illness:

History of past illness:

Personal history:

Menstrual history:

General Examination:

Height (cm) Weight (kg) BMI Pulse

(kg/m2) (/min)
BP (mm Hg) Pallor Cyanosis Jaundice

Clubbing Oedema Neck Neck

glands veins
Tongue / Eye / Ear Any
Teeth / other
gum findings

Systemic examination:

Cardio-vascular Central Nervous

System

Respiratory Genito-urinary

Gastro-intestinal

Laboratory Findings:

Provisional Diagnosis:

Management:

Page | 13
8. HEALTH STATUS OF INDIVIDUAL FAMILY MEMBERS (age above five years)
Sl. No ………… Date of examination: …………………………

Name : ……………………………………… Age: ……… Sex: ………..

History of present illness:

History of past illness:

Personal history:

Menstrual history:

General Examination:

Height (cm) Weight (kg) BMI Pulse

(kg/m2) (/min)
BP (mm Hg) Pallor Cyanosis Jaundice

Clubbing Oedema Neck Neck

glands veins
Tongue / Eye / Ear Any
Teeth / other
gum findings

Systemic examination:

Cardio-vascular Central Nervous

System

Respiratory Genito-urinary

Gastro-intestinal

Laboratory Findings:

Provisional Diagnosis:

Management:

Page | 14
8. HEALTH STATUS OF INDIVIDUAL FAMILY MEMBERS (age above five years)
Sl. No ………… Date of examination: …………………………

Name : ……………………………………… Age: ……… Sex: ………..

History of present illness:

History of past illness:

Personal history:

Menstrual history:

General Examination:

Height (cm) Weight (kg) BMI Pulse

(kg/m2) (/min)
BP (mm Hg) Pallor Cyanosis Jaundice

Clubbing Oedema Neck Neck

glands veins
Tongue / Eye / Ear Any
Teeth / other
gum findings

Systemic examination:

Cardio-vascular Central Nervous

System

Respiratory Genito-urinary

Gastro-intestinal

Laboratory Findings:

Provisional Diagnosis:

Management:

Page | 15
8. HEALTH STATUS OF INDIVIDUAL FAMILY MEMBERS (age above five years)
Sl. No ………… Date of examination: …………………………

Name : ……………………………………… Age: ……… Sex: ………..

History of present illness:

History of past illness:

Personal history:

Menstrual history:

General Examination:

Height (cm) Weight (kg) BMI Pulse

(kg/m2) (/min)
BP (mm Hg) Pallor Cyanosis Jaundice

Clubbing Oedema Neck Neck

glands veins
Tongue / Eye / Ear Any
Teeth / other
gum findings

Systemic examination:

Cardio-vascular Central Nervous

System

Respiratory Genito-urinary

Gastro-intestinal

Laboratory Findings:

Provisional Diagnosis:

Management:

Page | 16
8. HEALTH STATUS OF INDIVIDUAL FAMILY MEMBERS (age above five years)
Sl. No ………… Date of examination: …………………………

Name : ……………………………………… Age: ……… Sex: ………..

History of present illness:

History of past illness:

Personal history:

Menstrual history:

General Examination:

Height (cm) Weight (kg) BMI Pulse

(kg/m2) (/min)
BP (mm Hg) Pallor Cyanosis Jaundice

Clubbing Oedema Neck Neck

glands veins
Tongue / Eye / Ear Any
Teeth / other
gum findings

Systemic examination:

Cardio-vascular Central Nervous

System

Respiratory Genito-urinary

Gastro-intestinal

Laboratory Findings:

Provisional Diagnosis:

Management:

Page | 17
9A. ASSESSMENT OF YOUNG INFANT AGE UP TO 2 MONTHS (based on IMNCI)

Sl. No ....... Name: ......................... Age: .......... Sex: ......... Name of mother: ............................
Date of examination: ..................... Date of birth: ....................... Birth weight: ................
ANTHROPOMETRY: Weight: ................... Length: ..................

CHECK FOR POSSIBLE BACTERIAL INFECTION / JAUNDICE

Has the infant had convulsion? ........... Respirations per minute .........
Severe chest indrawing ......... Nasal fIaring ....... Grunting .........
Bulging fontanelle .......... Pus draining from the ear ........
Umbilicus (red or draining pus) ............... Skin pustules (10 or more or a big boil) ...............
Measure axillary temperature ........... Lethargic or unconscious: .......
Movements less than normal? ......... Jaundice .........
DOES THE YOUNG INFANT HAVE DIARRHOEA? Yes / No; If yes, For how long? .......
Blood in the stool? ..............
Infant’s general condition, Lethargic or unconscious? ............ Restless and irritable ...........
Sunken eyes ............. Skin Pinch: normal / slow / very slow (> 2 second)
CHECK FOR FEEDING PROBLEM & MALNUTRITION
Difficulty in feeding? Yes / No Weight for age: Very low / Low / Not Low
Is the infant breastfed? Yes / No; If Yes, how many times In 24 hours? .............. times
Child usually receives any other food or drink? Yes / No; If yes, how often? ...........
What do you use to feed the infant? .................................
ASSESS BREASTFEEDING:
Ask the mother to feed her child and observe
Is the infant able to attach? To check attachment, look for:
Chin touching breast: Yes / No Mouth wide open: Yes / No
Lower lip turned outward: Yes / No More areola above the mouth: Yes / No
Comment: No attachment at all / Not well attached / Good attachment
Is the infant suckling effectively (that is. slow deep sucks, sometimes pausing)?
Not suckling at all / Not suckling effectively / Suckling effectively
Ulcers or white patches in the mouth (thrush): Yes / No
Does the mother have pain while breastfeeding? Yes / No
If yes, look for: Flat or inverted nipples / Sore nipples / Engorged breasts / Breast abscess
LABORATORY FINDINGS:
PROVISIONAL DIAGNOSIS:
MANAGEMENT:

Page | 18
9B. ASSESSMENT OF YOUNG INFANT AGE 2 MONTHS UP TO 5 YEARS (based on IMNCI)

Sl. No ....... Name: ......................... Age: .......... Sex: ......... Name of mother: ............................
Date of examination: .....................Date of birth: ....................... Birth weight: ................
ANTHROPOMETRY: Weight: ................ Height/Length: ................. MUAC (1 – 5 yrs): ..........
CHECK FOR GENERAL DANGER SIGNS: Yes / No
Not able to drink or breastfeed / Vomits everything / Convulsions / Lethargic or unconscious
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes / No; If yes, how long? .....
Respiratory rate per min ............; Fast breathing? Yes / No
Chest indrawing? Yes / No; Stridor? Yes / No
DOES THE CHILD HAVE DIARRHOEA? Yes / No; If yes, For how long? .......
Blood in the stool? ..............
Child’s general condition, Lethargic or unconscious? ............ Restless and irritable ....
Sunken eyes .............
Offer the child fluid: Not able to drink or drinking poorly / Drinking eagerly, thirsty
Skin Pinch: normal / slow / very slow (> 2 second)
DOES THE CHILD HAVE FEVER? Yes / No
Decide Malaria Risk: High / Low; Fever for how long? .......Days
Stiff neck: Yes / No Bulging fontanelle: Yes / No Runny nose: Yes / No
Has the child had measles within the last 3 months? Yes / No
Look for signs of MEASLES
Generalised rash: Yes / No; Cough / runny nose / red eyes: Yes / No
Mouth ulcer: Yes / No Pus from the eye: Yes / No Clouding of cornea: Yes / No
DOES THE CHILD HAVE AN EAR PROBLEM: Yes / No
Ear pain? Yes / No Ear discharge? Yes / No, If yes, how long? ........
Pus draining from ear: Yes / No Tender swelling behind ear: Yes / No
CHECK FOR MALNUTRITION:
Visible severe wasting? Yes / No Oedema of both feet? Yes / No
Weight for age: Normal / Low / Very low
CHECK FOR ANEMIA / JAUNDICE: Palmer pallor: Yes / No Jaundice: Yes / No
ASSESS CHILD’S FEEDING:
Do you breastfeed your child? Yes / No; If Yes, how many times in 24 hours? …….
Do you breastfeed during the night? Yes / No
Does the child take any other food or fluids? Yes / No
If yes, what food / fluids? …………………………………..
How many times per day? ……… What you use to feed the child and how? ……………………
How large are the servings? ……………… Who feeds the child and how? …………………
During illness, does the child’s feeding changes? Yes / No, If yes how ……………….
LABORATORY FINDINGS:
PROVISIONAL DIAGNOSIS:
MANAGEMENT:

Page | 19
DEVELOPMENTAL MILESTONES:
Neck Sitting Crawling Standing Standing Walking Walking
holding with without with without
support support support support

Comment on development:

IMMUNISATION RECORD FOR UNDER-FIVE CHILD

Immunisation card available? Yes / No
BCG scar mark present? Yes / No
Vaccine Date Age of administration Remarks
BCG
OPV-0
OPV-1
OPV-2
OPV-3
OPV-B
Pentavalent-1 / DPT-1
Pentavalent-2 / DPT-2
Pentavalent-3 / DPT-3
Pentavalent-B / DPT-B
fIPV-1
fIPV-2
MCV-1 / MR-1
MCV-2 / MR-2
JE-1
JE-2
Vit A - 1
Vit A - 2
Vit A - 3
Vit A - 4
Vit A - 5
Vit A - 6
Vit A - 7
Vit A - 8
Vit A - 9
Any other (specify)

Comment on immunisation status:

Page | 20
Page | 21
Page | 22
9A. ASSESSMENT OF YOUNG INFANT AGE UP TO 2 MONTHS (based on IMNCI)

Sl. No ....... Name: ......................... Age: .......... Sex: ......... Name of mother: ............................
Date of examination: ..................... Date of birth: ....................... Birth weight: ................
ANTHROPOMETRY: Weight: ................... Length: ..................

CHECK FOR POSSIBLE BACTERIAL INFECTION / JAUNDICE

Has the infant had convulsion? ........... Respirations per minute .........
Severe chest indrawing ......... Nasal fIaring ....... Grunting .........
Bulging fontanelle .......... Pus draining from the ear ........
Umbilicus (red or draining pus) ............... Skin pustules (10 or more or a big boil) ...............
Measure axillary temperature ........... Lethargic or unconscious: .......
Movements less than normal? ......... Jaundice .........
DOES THE YOUNG INFANT HAVE DIARRHOEA? Yes / No; If yes, For how long? .......
Blood in the stool? ..............
Infant’s general condition, Lethargic or unconscious? ............ Restless and irritable ...........
Sunken eyes ............. Skin Pinch: normal / slow / very slow (> 2 second)
CHECK FOR FEEDING PROBLEM & MALNUTRITION
Difficulty in feeding? Yes / No Weight for age: Very low / Low / Not Low
Is the infant breastfed? Yes / No; If Yes, how many times In 24 hours? .............. times
Child usually receives any other food or drink? Yes / No; If yes, how often? ...........
What do you use to feed the infant? .................................
ASSESS BREASTFEEDING:
Ask the mother to feed her child and observe
Is the infant able to attach? To check attachment, look for:
Chin touching breast: Yes / No Mouth wide open: Yes / No
Lower lip turned outward: Yes / No More areola above the mouth: Yes / No
Comment: No attachment at all / Not well attached / Good attachment
Is the infant suckling effectively (that is. slow deep sucks, sometimes pausing)?
Not suckling at all / Not suckling effectively / Suckling effectively
Ulcers or white patches in the mouth (thrush): Yes / No
Does the mother have pain while breastfeeding? Yes / No
If yes, look for: Flat or inverted nipples / Sore nipples / Engorged breasts / Breast abscess
LABORATORY FINDINGS:
PROVISIONAL DIAGNOSIS:
MANAGEMENT:

Page | 23
9B. ASSESSMENT OF YOUNG INFANT AGE 2 MONTHS UP TO 5 YEARS (based on IMNCI)

Sl. No ....... Name: ......................... Age: .......... Sex: ......... Name of mother: ............................
Date of examination: .....................Date of birth: ....................... Birth weight: ................
ANTHROPOMETRY: Weight: ................ Height/Length: ................. MUAC (1 – 5 yrs): ..........
CHECK FOR GENERAL DANGER SIGNS: Yes / No
Not able to drink or breastfeed / Vomits everything / Convulsions / Lethargic or unconscious
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes / No; If yes, how long? .....
Respiratory rate per min ............; Fast breathing? Yes / No
Chest indrawing? Yes / No; Stridor? Yes / No
DOES THE CHILD HAVE DIARRHOEA? Yes / No; If yes, For how long? .......
Blood in the stool? ..............
Child’s general condition, Lethargic or unconscious? ............ Restless and irritable ....
Sunken eyes .............
Offer the child fluid: Not able to drink or drinking poorly / Drinking eagerly, thirsty
Skin Pinch: normal / slow / very slow (> 2 second)
DOES THE CHILD HAVE FEVER? Yes / No
Decide Malaria Risk: High / Low; Fever for how long? .......Days
Stiff neck: Yes / No Bulging fontanelle: Yes / No Runny nose: Yes / No
Has the child had measles within the last 3 months? Yes / No
Look for signs of MEASLES
Generalised rash: Yes / No; Cough / runny nose / red eyes: Yes / No
Mouth ulcer: Yes / No Pus from the eye: Yes / No Clouding of cornea: Yes / No
DOES THE CHILD HAVE AN EAR PROBLEM: Yes / No
Ear pain? Yes / No Ear discharge? Yes / No, If yes, how long? ........
Pus draining from ear: Yes / No Tender swelling behind ear: Yes / No
CHECK FOR MALNUTRITION:
Visible severe wasting? Yes / No Oedema of both feet? Yes / No
Weight for age: Normal / Low / Very low
CHECK FOR ANEMIA / JAUNDICE: Palmer pallor: Yes / No Jaundice: Yes / No
ASSESS CHILD’S FEEDING:
Do you breastfeed your child? Yes / No; If Yes, how many times in 24 hours? …….
Do you breastfeed during the night? Yes / No
Does the child take any other food or fluids? Yes / No
If yes, what food / fluids? …………………………………..
How many times per day? ……… What you use to feed the child and how? ……………………
How large are the servings? ……………… Who feeds the child and how? …………………
During illness, does the child’s feeding changes? Yes / No, If yes how ……………….
LABORATORY FINDINGS:
PROVISIONAL DIAGNOSIS:
MANAGEMENT:

Page | 24
DEVELOPMENTAL MILESTONES:
Neck Sitting Crawling Standing Standing Walking Walking
holding with without with without
support support support support

Comment on development:

IMMUNISATION RECORD FOR UNDER-FIVE CHILD

Immunisation card available? Yes / No
BCG scar mark present? Yes / No
Vaccine Date Age of administration Remarks
BCG
OPV-0
OPV-1
OPV-2
OPV-3
OPV-B
Pentavalent-1 / DPT-1
Pentavalent-2 / DPT-2
Pentavalent-3 / DPT-3
Pentavalent-B / DPT-B
fIPV-1
fIPV-2
MCV-1 / MR-1
MCV-2 / MR-2
JE-1
JE-2
Vit A - 1
Vit A - 2
Vit A - 3
Vit A - 4
Vit A - 5
Vit A - 6
Vit A - 7
Vit A - 8
Vit A - 9
Any other (specify)

Comment on immunisation status:

Page | 25
Page | 26
Page | 27
9A. ASSESSMENT OF YOUNG INFANT AGE UP TO 2 MONTHS (based on IMNCI)

Sl. No ....... Name: ......................... Age: .......... Sex: ......... Name of mother: ............................
Date of examination: ..................... Date of birth: ....................... Birth weight: ................
ANTHROPOMETRY: Weight: ................... Length: ..................

CHECK FOR POSSIBLE BACTERIAL INFECTION / JAUNDICE

Has the infant had convulsion? ........... Respirations per minute .........
Severe chest indrawing ......... Nasal fIaring ....... Grunting .........
Bulging fontanelle .......... Pus draining from the ear ........
Umbilicus (red or draining pus) ............... Skin pustules (10 or more or a big boil) ...............
Measure axillary temperature ........... Lethargic or unconscious: .......
Movements less than normal? ......... Jaundice .........
DOES THE YOUNG INFANT HAVE DIARRHOEA? Yes / No; If yes, For how long? .......
Blood in the stool? ..............
Infant’s general condition, Lethargic or unconscious? ............ Restless and irritable ...........
Sunken eyes ............. Skin Pinch: normal / slow / very slow (> 2 second)
CHECK FOR FEEDING PROBLEM & MALNUTRITION
Difficulty in feeding? Yes / No Weight for age: Very low / Low / Not Low
Is the infant breastfed? Yes / No; If Yes, how many times In 24 hours? .............. times
Child usually receives any other food or drink? Yes / No; If yes, how often? ...........
What do you use to feed the infant? .................................
ASSESS BREASTFEEDING:
Ask the mother to feed her child and observe
Is the infant able to attach? To check attachment, look for:
Chin touching breast: Yes / No Mouth wide open: Yes / No
Lower lip turned outward: Yes / No More areola above the mouth: Yes / No
Comment: No attachment at all / Not well attached / Good attachment
Is the infant suckling effectively (that is. slow deep sucks, sometimes pausing)?
Not suckling at all / Not suckling effectively / Suckling effectively
Ulcers or white patches in the mouth (thrush): Yes / No
Does the mother have pain while breastfeeding? Yes / No
If yes, look for: Flat or inverted nipples / Sore nipples / Engorged breasts / Breast abscess
LABORATORY FINDINGS:
PROVISIONAL DIAGNOSIS:
MANAGEMENT:

Page | 28
9B. ASSESSMENT OF YOUNG INFANT AGE 2 MONTHS UP TO 5 YEARS (based on IMNCI)

Sl. No ....... Name: ......................... Age: .......... Sex: ......... Name of mother: ............................
Date of examination: .....................Date of birth: ....................... Birth weight: ................
ANTHROPOMETRY: Weight: ................ Height/Length: ................. MUAC (1 – 5 yrs): ..........
CHECK FOR GENERAL DANGER SIGNS: Yes / No
Not able to drink or breastfeed / Vomits everything / Convulsions / Lethargic or unconscious
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes / No; If yes, how long? .....
Respiratory rate per min ............; Fast breathing? Yes / No
Chest indrawing? Yes / No; Stridor? Yes / No
DOES THE CHILD HAVE DIARRHOEA? Yes / No; If yes, For how long? .......
Blood in the stool? ..............
Child’s general condition, Lethargic or unconscious? ............ Restless and irritable ....
Sunken eyes .............
Offer the child fluid: Not able to drink or drinking poorly / Drinking eagerly, thirsty
Skin Pinch: normal / slow / very slow (> 2 second)
DOES THE CHILD HAVE FEVER? Yes / No
Decide Malaria Risk: High / Low; Fever for how long? .......Days
Stiff neck: Yes / No Bulging fontanelle: Yes / No Runny nose: Yes / No
Has the child had measles within the last 3 months? Yes / No
Look for signs of MEASLES
Generalised rash: Yes / No; Cough / runny nose / red eyes: Yes / No
Mouth ulcer: Yes / No Pus from the eye: Yes / No Clouding of cornea: Yes / No
DOES THE CHILD HAVE AN EAR PROBLEM: Yes / No
Ear pain? Yes / No Ear discharge? Yes / No, If yes, how long? ........
Pus draining from ear: Yes / No Tender swelling behind ear: Yes / No
CHECK FOR MALNUTRITION:
Visible severe wasting? Yes / No Oedema of both feet? Yes / No
Weight for age: Normal / Low / Very low
CHECK FOR ANEMIA / JAUNDICE: Palmer pallor: Yes / No Jaundice: Yes / No
ASSESS CHILD’S FEEDING:
Do you breastfeed your child? Yes / No; If Yes, how many times in 24 hours? …….
Do you breastfeed during the night? Yes / No
Does the child take any other food or fluids? Yes / No
If yes, what food / fluids? …………………………………..
How many times per day? ……… What you use to feed the child and how? ……………………
How large are the servings? ……………… Who feeds the child and how? …………………
During illness, does the child’s feeding changes? Yes / No, If yes how ……………….
LABORATORY FINDINGS:
PROVISIONAL DIAGNOSIS:
MANAGEMENT:

Page | 29
DEVELOPMENTAL MILESTONES:
Neck Sitting Crawling Standing Standing Walking Walking
holding with without with without
support support support support

Comment on development:

IMMUNISATION RECORD FOR UNDER-FIVE CHILD

Immunisation card available? Yes / No
BCG scar mark present? Yes / No
Vaccine Date Age of administration Remarks
BCG
OPV-0
OPV-1
OPV-2
OPV-3
OPV-B
Pentavalent-1 / DPT-1
Pentavalent-2 / DPT-2
Pentavalent-3 / DPT-3
Pentavalent-B / DPT-B
fIPV-1
fIPV-2
MCV-1 / MR-1
MCV-2 / MR-2
JE-1
JE-2
Vit A - 1
Vit A - 2
Vit A - 3
Vit A - 4
Vit A - 5
Vit A - 6
Vit A - 7
Vit A - 8
Vit A - 9
Any other (specify)

Comment on immunisation status:

Page | 30
Page | 31
Page | 32
10. MATERNITY RECORD
A. Antenatal Record

Name of the mother: ........................................... Husband’s name: .......................................

Age (yrs) : .............. Age at marriage: ..............
Gravida: ..................... LMP: ........................... EDD: ...........................
Date of registration: ........................ No. of antenatal visits made: ...................
Tetanus toxoid: 1st dose ................... 2nd dose ................ Booster Dose .....................
IFA tablets consumed: Yes / No If yes, number consumed: ...........
If no, reasons:
Other treatment received: Yes / No If yes, specify:
H/o present illness:
H/o past illness:
Any significant illness: Diabetes / HTN I TB / STD / Heart Disease / any other (specify) ........
Any significant family history of illness: Diabetes / HTN I Twins I any other (specify) ...........

History of previous pregnancy:

Outcome: Present
Order of Age at Live birth Type of Place of Conducted Complications health
pregnancy pregnancy / Stillbirth delivery delivery by: , if any status of
/ Abortion the child

General examination:
Height Weight Pulse BP Pallor Jaundice Oedema Others

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Systemic Examination:

Central
Cardio-vascular Nervous
System

Respiratory Genito-urinary

Gastro-intestinal

Obstetric Examination: Fundal height ................... FHS .......................

Laboratory Examination:
Hb%: Blood group PP Blood VDRL Urine
/ Rh type sugar protein sugar pus cells

Antenatal advice received:

Antenatal advice given during family visit:

B. Intranatal record:
Date of delivery:
Delivered by: Doctor / Nurse / TBA / Others (specify)
Place of delivery: Home /Govt. facilities /Private health facility /others (specify)
Type of delivery: Normal / Assisted / LUCS / Others (specify)
Outcome of pregnancy: Full-term / Premature / Abortion / MTP / Stillbirth
Sex of the child: Male / Female Birth weight: ....................
Complications, if any:
C. Postnatal record:
No. of post natal visits received: ................
Postnatal complaints, if any:
Post natal examination:

Pulse BP Temp. Edema Pallor Jaundice Lochia Breast

Advice for family planning given: Yes / No If yes, By whom:

Method accepted:

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11. HEALTH KNOWLEDGE OF THE FAMILY
Name of respondent: .......................
A. Health seeking behaviour

Where from they take treatment / service for:

Immunization:
Antenatal care:
Delivery:
Postnatal care:
Family planning:
<5 yrs care:
Emergency:
Other illnesses:

Preferred system of medicine: Modern medicine / AYUSH / both

Reasons for not attending government facilities:

Non-availability of drugs / Distance / Time Consuming / Expensive / Behaviour of
staff / Indifference / Lack of faith / Others(specify)

B. Health knowledge of the family about common diseases: Communicable

Disease Causation / Prevention Treatment

transmission

Diarrhoea

Worm infestation

Measles

Chicken pox

Malaria

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 Disease Causation / Prevention Treatment
transmission

Dengue

Leprosy

Tuberculosis

HIV / AIDS / STI

C. Health knowledge of the family about common diseases: Non-Communicable

Disease Causation Prevention Treatment

Hypertension

Diabetes

Cancer

Heart disease

Thyroid disorder

COPD / Asthma

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 D. Health knowledge of the eligible couple(s) about family planning :

Number of eligible couples in the family: ............

Knowledge about family planning: Couple 1 (wife ..............) Couple 2 (wife ..............)
i. What should be the minimum
interval between two
pregnancies?
ii. Do you know how to prevent
birth?
iii. Methods known to prevent
births?
iv. What is the source of the
knowledge?
v. Where are MTP services
available?
Attitude towards Family Planning :
i. No. of children the family
desires
Husband’s opinion Boys Girls Boys Girls
Wife’s opinion Boys Girls Boys Girls
ii. Suitable spacing between
children
Husband’s opinion:

Wife’s opinion:
iii. Place of procuring the
contraceptives
iv. Decision taken for permanent
method
v. If needed will they avail MTP
Services
Practice regarding Family Planning
i. Age at marriage
Husband
Wife
ii. Age at first pregnancy
iii. Total number of children in the
family
iv. Intervals between children:

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 Couple 1 Couple 2
v. Contraception practice
a. Do they presently practice
Family Planning? (Y / N)
b. If yes, method being currently
used:
c. Since when?
d. Any method used previously
and discontinued? (Yes / No)

e. If yes, specify and cause of

discontinuation:
f. Any history of induced
abortion? (Yes / No)

g. If yes, place of MTP service

E. Knowledge and practice regarding infant feeding

Infant feeding Knowledge Practice

Initiation of breastfeeding

Prelacteal feeding

Colostrum feeding

Exclusive breast feeding

with duration

Complementary feeding
- Initiation

- Type of food

Feeding during illness

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12. NUTRITIONAL PROFILE OF THE FAMILY
Method used for dietary survey:

A. Quantity of food consumed by the family on the day before diet survey

Food group Food item Quantity consumed (gm / ml)

Rice
Wheat
Bread
Cereals Puffed rice (muri)
Flattened rice (chira)
Sattu
Noodles

Pulses

Roots & tubers

Green leafy vegetables

Other vegetables

Flesh food

Milk & milk products

Fruits

Fats & oils

Sugar & jaggery

Total

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 B. Nutritive value of food items consumed:

Food group Food Qty in Energy Protein Fat Iron Vit A Vit C Calcium
item gm (Kcal) (gm) (gm) (mg) (mcg) (mgm) (mgm)
Cereals

Pulses

Roots &
tubers

Green leafy
vegetables

Other
vegetables

Flesh food

Milk & milk

products
Fruits

Fats & oils

Tea / coffee

Sugar &
jaggery
Total

C. Daily nutrient requirement of the family

Sl Age Sex Work Wt Energy Protein Fat Iron Vit A Vit C Calcium
No Type (kg) (Kcal) (gm) (gm) (mg) (mcg) (mg) (mg)

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D. Comparison of daily requirement and consumption of the NUTRIENTS

Total Total Deficit (-) / % Deficit (-) /

Nutrient
consumption requirement Excess (+) Excess (+)
Energy (Kcal)

Protein (gm)

Fat (gm)

Iron (mg)

Vit A (mcg)

Vit C (mg)

Calcium (mg)

E. Comparison of daily requirement and consumption of different FOOD GROUPS

Total Total Deficit (-) / % Deficit (-) /

Food group
consumption requirement Excess (+) Excess (+)
Cereals

Pulses

Roots & tubers

Green leafy
vegetables
Other
vegetables
Flesh food
Milk & milk
products
Fruits

Fats & oils

Sugar & jaggery

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F. Bar diagram showing daily deficit / excess of nutrients G. Bar diagram showing daily deficit / excess of different food groups

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13. SUMMARY

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Page | 44
14. FAMILY DIAGNOSIS

15. ACTIONS TAKEN

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16. RECOMMENDATIONS

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17A. ACKNOWLEDGEMENT

17B. BIBLIOGRAPHY

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