DEPARTMENT OF COMMUNITY MEDICINE FAMILY ADOPT

DATE OF ALLOTMENT:

SERIAL NUMBER:

NAME OF THE STUDENT:

BATCH:
ROLL NUMBER:
NAME and SIGNATURE OF THE
MENTOR:
NAME OF HEAD OF ADOPTED
FAMILY:

CLINICO SOCIAL DIAGNOSIS

PHONE:
MOBILE:

LANDLINE
ADDRESS:

AADHAAR CARD:
ASHA WORKER OF THE ALLOTTED
AREA:

SIGNATURE OF STUDENT:
MEDICINE FAMILY ADOPTION PROGRAM
 Relatio
DOB/ Marital
Sl.no Name Sex n to Education Occupation
AGE status
HOF

M/UM/
1.1 M/F
W

M/UM/
1.2 M/F
W

M/UM/
1.3 M/F
W

M/UM/
1.4 M/F
W
 M/UM/
1.5 M/F
W

M/UM/
1.6 M/F
W

16-64
Age <1 yr 1-5 yr 6-15 yr yr >65 yr Total

Male

Female
 FAMILY PROFILE
1 FAMILY DETAILS (Please fill in the details of the members of family

Diet
Name Any
Monthly and Addicti
of health
Income (In Consu ons (if Height weight PR BP
school conditi
Rs) mption any)
of child ons
unit
 Per capita
income:

SES score:
Social security Old age pension/Ayushman
schemes: Bharat/ESI/Other:_____
Ration card Available/Not available

ABHA card Available/Not available

bers of family

Medico
Blood immunization
RR RBS Haemglobin(%) social
group status
status
2 INFORMATION ABOUT T
Locality where staying:
Staying since
Connectivity
Own house
Type of house:
Vital events in family (last 1year) Birth/Death/Marriag
Type of family:
Light
Ventilation
Overcrowding
Source of water supply: Hand pump/House ta

Purification of water before

consumption

Latrine facility for children Household Latrine/C

Latrine facility for adults Household Latrine/C

Kitchen
Fuel for cooking
Disposal of dry Household waste

Disposal of wet household waste

Any vectors/vector breeding

sites/Pet animals/Cattle:

Household amenities
wheeler/Internet/

3
 (For currently pregnant women and m
Name:
Obstetric score: ____________ Age at birth of last child: __

Whether mother has /

3.1
had registered for ANC:

Whether IFA tablets

3.2 were consumed during
pregnancy:
Whether Inj. TT was Not applicable (not a
3.3 administered during
pregnancy:
Whether used any
3.4 family planning method
in the past
Enrolled in any national
3.5
program
Availed health services
3.6
from:

4 INFANT HEALTH (If infants p

a. Name & Place of delivery: Govt/Private/Other:_______
b. Type of delivery: Vaginal/Caesarean/Other:__________
c. Gender & Age: _____________________
d. What was the birth weight of the baby _____________
e. Within how many hours after birth, breastfeeding was
f. Only breast milk is given to the baby in the first 6 months. If
< 6 months: _________________________________________
For how long should a
mother breastfeedher
4.7
baby? (To test the
mother’s knowledge)
 For how long should a
mother bottle-feedher
4.8 NEVER to be bottle-fed. If f
baby? (To test mother’s
knowledge)
At what age of baby (in
months) themother
4.9
completely stopped
breastfeeding?

Not applicable (baby exclu

At what age of baby (in
4.1 months) the following
feeds were given? Semi-solid feeds_____

4.11 Enrolled in any national

programs
Availing health services
4.12
from:
INFORMATION ABOUT THE HOUSEHOLD

____ years ____ months

YES/NO
Kutcha/Pucca/semi pucca/others:_______
Birth/Death/Marriage/Adoption/Divorce/others:________
Nuclear/ Joint/ Extended
Adequate/Inadequate
Cross ventilation: Absent/Present
Yes/No
Hand pump/House tap/Well/Street tap/Others:__________
No purification done
Filtering with cloth Boiling
Branded water filters
Other: ________

Household Latrine/Community Latrine/ Other: _________

Household Latrine/Community Latrine/ Other: _________

LPG/kerosene/Firewood/Gas/Other:__________
Open dumping/BBMP/others:_____

Open dumping/BBMP/others:_____

Yes:_________ Which sites:________

No
Television/computer/Fridge/Two wheeler/Four
wheeler/Internet/washing machine/NIL/Others:_____

MATERNAL HEALTH
tly pregnant women and mothers of infants only)
Age: Pregnant/Lactating
Age at birth of last child: ______ Age at 1st pregnancy:______

Not registered for ANC

Place of registration for ANC: Govt/Municipal/Private
Duration of pregnancy at first ANC check-up
How many times you went for an ANC check- up
Not applicable (not consumed IFA)

Duration of IFA consumption( if consumed):

Not applicable (not administered Inj. TT) First dose of Inj TT:
Yes/No
Second dose of Inj TT: Yes/No
Never used Condom IUCD
Oral Pills
Other _________

Govt/Private/Others________

NFANT HEALTH (If infants present during study)

ovt/Private/Other:_______________________________
esarean/Other:_______________________________
___________ Age (in months): ___________
of the baby ___________________________________
er birth, breastfeeding was started:_______________________
aby in the first 6 months. If not, what feeds were given to the baby (baby
________________________________________

Duration of breast feeding:_______ _ Sure/Not sure

Don’t know
NEVER to be bottle-fed. If fed Duration of bottle feeding : ____________

Not applicable (baby still breastfed)

Stopped when the baby was _______ months

Not applicable (baby exclusively breastfed) Liquid feeds _____months

Semi-solid feeds_______ months Solid foods________ months

Govt/private/others:___________
 5. FOR 0–5-YEAR-OLD CHILDREN (IMMUNIZAT
Child - 1

5.1 Name:

5.2 Age(months)

5.3 Gender: F M

5.4 Height

5.5 Weight

5.6 Immunization

BCG Yes No
at birth OPV Zero Yes No
Hep B Birth
Yes No
dose
OPV -1 Yes No
6 weeks IPV -1 Yes No
Pentavalent -1 Yes No
10 OPV - 2 Yes No
weeks Pentavalent -2 Yes No
OPV - 3 Yes No
14 IPV - 2 Yes No
weeks
Pentavalent - 3 Yes No
Measles / MR -
Yes No
9 1
months Vitamin A (1
Yes No
lakh IU)
16- 24 Measles / MR -
Yes No
months 2
Vitamin A (2
Yes No
lakh IU)
5 years OPV Booster Yes No
DPT Booster - 1 Yes No

DPT Booster - 2 No
6- monthly Vit.
Yes No
A

Govt/Municipal/
Facility where vaccinated
Private// Other

Yes/No Card
Verified with incomplete
Immunization. Card
No card

BCG Scar Yes/No

Reason for NOT

vaccinating (if any)

More than 3 yrs. going to

Yes/No
Anganwadi

Current health problems

of the child if any

6. FOR 6–15-YEAR-OLD CHILDREN

Child - 1
6.1 Name:
 6.2 Age(years):
6.3 Gender: F M
Attending
Current school/ Never
6.4
schooling status enrolled/
Dropped out
If child is attending school,
Class in which
6.5
child is studying

Mid-Day Meal
Daily/ Irregular/
6.6 provided free of
Not provided
cost at school

School Good/Average/B
6.7
Performance ad
If child is not attending school
Reason for not
6.7 attending
school
Current health
6.8 problems of
child if any
If the child is
10+ years old -
6.9 Yes/No/NA
dose Inj.TT
given
LDREN (IMMUNIZATION STATUS)
Child – 2 Child – 3

F M F M

Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No

Yes No Yes No

Yes No Yes No
 Yes No Yes No

Yes No Yes No
Yes No Yes No
Yes No Yes No

Yes No Yes No

Yes No Yes No

Govt/Municipal/ Govt/Municipal/
Private// Other Private// Other

Yes/No Card Yes/No Card

incomplete incomplete

No card No card

Yes/No Yes/No

Yes/No Yes/No

Child - 2 Child - 3
 F M F M
Attending Attending
school/Never school/Never
enrolled/ enrolled/
Dropped out Dropped out

Daily/ Irregular/ Daily/ Irregular/

Not provided Not provided

Good/Average/B Good/Average/B
ad ad

Yes/No/NA Yes/No/NA
 7
Name:
Sex: M/F
financially dependent/independent
Adult 1
a. weight
b.Height
c. BMI
d. PR
e. BP
f. RR
g. Comorbidities
h.Visual problems:
Cataract/Refractive
errors/Vitamin A deficiency
i. CVS
j. RS
k. CNS
l. Hearing problems:
Yes/No
m. Goitre
n. Urinary problems
o. Reproductive tract
problems
p. TB/Leprosy
q. Dental problems
r. Gynaecological
problems
s. Disability
t. Psychiatry illness
u. Cancer
v. anemia
w. COVID 19

x. bone/joint problems
y. availing hospital
services:
z. Enrolled in any national
programs
 ADULTS (16 to above 60yrs)
Age:
Employed/Unemployed/Retired
Occupation: Student/working
Adult 2 Adult 3 Adult 4
 st
7. FOLLOW-UP (1 MBBS)

1st 2nd
3rd 4th Follow-
Follow- Follow-
Follow-up up
up up

Date:

Findings:

Remarks

7. FOLLOW – UP (2nd MBBS)

st 2nd
1 Follow – 3rd Follow 4th Follow
Follow –
Up – Up – Up
Up
Date:

Findings:

Remarks

7. FOLLOW- UP (3RD MBBS)

st 2nd
1 Follow – 3rd Follow 4th Follow
Follow –
Up – Up – Up
Up
Date:

Findings:

Remarks
 5th 6th 7th 8th 9th
Follow- Follow- Follow- Follow- Follow-
up up up up up

5th 6th
Follow Follow
– Up – Up

5th
Follow
– Up