Fap Proforma

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FAMILY-…….

SOCIO- DEMOGRAPHIC PROFILE OF THE FAMILY: DATE: ___________

Name of Head of the family:

Complete Address:

Contact Number: ________________________________

Marital status: Unmarried/Married/Divorce/Separated/Widowed

Type of family : Nuclear/Joint/Three generation

Total number of Family members:

Total income of family: _________________Per capita income: ______________________

BG Prasad Socio economic class: (Tick the appropriate option)


1. Class I 2. Class II 3. Class III 4. Class IV 5. Class V
Religion: 1. Hindu 2. Christian 3. Muslim 4. Others (specify): ________________

Nearby health facility: 1. Government_____________2.Private ____________Distance:


___________

Usual source of medical care: 1. Hospital(Govt/Private) 2. Govt Primary Health centre 3.


Private practitioner 4. Others,specify_______________________

Preferred system of medicine: 1. Allopathy 2. Ayurveda 3. Yoga 4.Unani 5.


Siddha 6. Homeopathy 7.Others,____________

ICDS Beneficiaries: 1. Antenatal / Postnatal mother 2.Children 0-6 years 3. Adolescent


girls(11-18 years)

Special groups in the family: 1. Antenatal / Postnatal mothers 2. Under 5 children


3.Geriatric people 4. Differently abled people
Vital events in the past 1 year: 1. Births (Y/N) 2. Deaths (Y/N) 3. Marriages (Y/N)
4.Divorce (Y/N) 5. Migration (Y/N)

Covered under any health insurance / schemes: 1. State Government 2. Central


Government 3. ESI 4.Private 5. Others (specify): __________________ 6.None

FAMILY STRUCTURE

S.no Age in completed years Number Total


Male Female
1. Infants (<1 year)
2. 1- 5 years
3. 6 – 14 years
4. 15 – 48 years
5. 49 – 60 years
6. 60-64 years
7. >64 Years
Total

DEPENDENCY STATUS:

Total dependency(young age + Old age) = Number of children 0-14 years age + Population
more than 65 years of age

Dependency ratio:

Number of children 0-14 years age (+ ) Population more than 65 years of age /Population of
15 to 64 years X 100=
Environmental details

House 1. Own House 2. Rental House


Type of house 1.Kutcha 2. Pucca 3. Semi-pucca
Duration of stay in current house
Approximate size of living space of
household(Sq.ft)
Number of living rooms
Setback area 1.Present 2. Absent
Overcrowding 1.Present 2. Absent
Ventilation 1.Adequate 2.Inadequate
Cross-Ventilation 1.Present 2. Absent
Lighting 1. Natural (Adequate/Inadequate), 2.
Artificial(Adequate/Inadequate)
KITCHEN
Separate Kitchen 1.Yes 2.No
Type of cooking fuel 1.LPG 2.Firewood 3.Kerosene stove
4.Electric 5.Mixed
Food Storage facilities 1.Yes 2.No
Smoke Outlet 1. Present 2. Absent
WATER
Sources of drinking water 1.Bore well 2.Public tap 3.Mineral /RO water
4.Others__________
Sources of water for Domestic purpose 1.Bore well 2.Public tap
Water purification process followed 1.Boiling 2. Filtering 3.Chlorination
4.Others
Storage 1. Sanitary 2.Insanitary
SANITATION
Latrine 1.Own 2.Shared 3.Public Latrine
Cleanliness of toilet 1. Sanitary 2.Insanitary
Water supply 1. Continuos 2. Intermittent 3.No piped water supply
Solid Waste disposal-Garbage
How it is stored inside the house? 1. Dust bins 2. Plastic covers 3.
Disposal details Others,Specify__________________
1. Dumping 2. Landfill 3. Collection by panchayat 4.
Others,Specify________
Sewage disposal 1. Septic tank 2. Underground drainage system 3.
Open air defecation 4. Others _____________
Sullage disposal
1.Soakage pit 2. Open drainage 2. Closed drainage
4. Gardens 5. Others _________________
ANIMALS:
Animal(s) Reared: 1.Yes 2.No If Yes,
Pets/Domestic(specify)_____________

Cattle Shed: 1.Present 2. Absent Distance _____________

Rodents: 1.Present 2. Absent


1.Present 2. Absent
Vector Breeding Sites:
Details of Tree plantation activities

DRAW THE HOUSING PLAN:


SOCIO-CULTURAL PRACTICES:

S.no Practices Details of practice Remarks

1. Personal hygiene of the


family members -Bathing,
hand washing, oral hygiene
etc

2. Indiscriminate spitting in
and around the house

3. Addictions:

Smoking & tobacco usage

Alcohol

4. Cow dung smearing to


floor

Other practices: (specify, if any):


PRACTICES AMONG WOMEN AND CHILDREN:

S.no Practices Details of practice

1. Age at marriage of boys and girls

2. Consanguineous marriage
3. Menstrual hygiene a)Cloth b)Napkin c)Others………….
Frequency of Changing it:
4. Maternal and child health practices
Pregnancy& Lactation – Special diet,
physical activity, Antenatal care, Exclusive
breast feeding
Mention any other customs followed

5. Child Rearing practices- Oil bath,


applying kajal, usual time of
commencement of breast feeding,
colostrum given or not, prelacteal feeds,
- Artificial milk – bottle feeding or
spoon
- Age at which weaning is started
and foods introduced
- Any other custom
6. Attitude towards Immunization
Immunization details of the child:

7. Details of Family planning


Family size decision

8. Preference for male child


DIETARY PRACTICES:

Type of diet: 1. Vegetarian 2. Mixed diet 3. Others, specify_____________________

Meal pattern: Bed tea, Breakfast, Mid-morning Lunch, Evening tea, Dinner, bedtime drink.

Write about the Family’s Meal Pattern: (24hour recall method)

Average Monthly Expenditure on Food:

Particulars Inference

Staple diet Rice/Wheat/Millets


Using greens, vegetables, fruits, Yes/No
Fermentation of grains Yes/No
Sprouting of grains Yes/No
Use of Iodized salts Yes/No

Family food practices:

Mention any food taboos, restrictions and prejudice in the family:


Assessment of Knowledge Attitude and Practices

Health particulars Knowledge Attitude (Beliefs Practices


(Good/Average/ and Customs) Yes/No
Poor) (Positive/Negative) If Yes-Regular/Irregular
Healthy lifestyle

Prevention of Common
diseases

Family planning
services

Sanitation and hygiene

Psychiatric condition

Environmental
protection

FELT NEEDS OF THE FAMILY

HEALTH NEEDS GENERAL NEEDS


FAMILY HEALTH PROFILE

Examine and interview all the family members present during your visit. Briefly summarize the
findings.

1) NAME: ………………………………………………Age/Sex………….. Date of Visit……………..

CHIEF COMPLAINTS

PAST HISTORY

PERSONAL HISTORY

TREATMENT HISTORY

IMMUNIZATION STATUS:

COVID VACCINATION a)Single dose b)Double dose c) Booster


STATUS:

GENERAL EXAMINATION TEMPERATURE: PULSE: BP: RR:


HEIGHT (cms): WEIGHT (kg): BMI:

SYSYTEMIC
EXAMINATION

DIAGNOSIS/SUMMARY
OF THE FINDINGS

MANAGEMENT

INVESTIGATIONS HEMOGLOBIN: URINE PROTEIN:

BLOOD SUGAR: URINE SUGAR:

BLOOD GROUP:

ADVICE GIVEN

FOLLOW UP
2) NAME: ………………………………………………Age/Sex………….. Date of Visit……………..

CHIEF COMPLAINTS

PAST HISTORY

PERSONAL HISTORY

TREATMENT HISTORY

IMMUNIZATION STATUS:

COVID VACCINATION a)Single dose b)Double dose c) Booster


STATUS:

GENERAL EXAMINATION TEMPERATURE: PULSE: BP: RR:


HEIGHT (cms): WEIGHT (kg): BMI:

SYSYTEMIC
EXAMINATION

DIAGNOSIS/SUMMARY
OF THE FINDINGS

MANAGEMENT

INVESTIGATIONS HEMOGLOBIN: URINE PROTEIN:

BLOOD SUGAR: URINE SUGAR:

BLOOD GROUP:

ADVICE GIVEN

FOLLOW UP
3) NAME: ………………………………………………Age/Sex………….. Date of Visit……………..

CHIEF COMPLAINTS

PAST HISTORY

PERSONAL HISTORY

TREATMENT HISTORY

IMMUNIZATION STATUS:

COVID VACCINATION a)Single dose b)Double dose c) Booster


STATUS:

GENERAL EXAMINATION TEMPERATURE: PULSE: BP: RR:


HEIGHT (cms): WEIGHT (kg): BMI:

SYSYTEMIC
EXAMINATION

DIAGNOSIS/SUMMARY
OF THE FINDINGS

MANAGEMENT

INVESTIGATIONS HEMOGLOBIN: URINE PROTEIN:

BLOOD SUGAR: URINE SUGAR:

BLOOD GROUP:

ADVICE GIVEN

FOLLOW UP
4) NAME: ………………………………………………Age/Sex………….. Date of Visit……………..

CHIEF COMPLAINTS

PAST HISTORY

PERSONAL HISTORY

TREATMENT HISTORY

IMMUNIZATION STATUS:

COVID VACCINATION a)Single dose b)Double dose c) Booster


STATUS:

GENERAL EXAMINATION TEMPERATURE: PULSE: BP: RR:


HEIGHT (cms): WEIGHT (kg): BMI:

SYSYTEMIC
EXAMINATION

DIAGNOSIS/SUMMARY
OF THE FINDINGS

MANAGEMENT

INVESTIGATIONS HEMOGLOBIN: URINE PROTEIN:

BLOOD SUGAR: URINE SUGAR:

BLOOD GROUP:

ADVICE GIVEN

FOLLOW UP
5) NAME: ………………………………………………Age/Sex………….. Date of Visit……………..

CHIEF COMPLAINTS

PAST HISTORY

PERSONAL HISTORY

TREATMENT HISTORY

IMMUNIZATION STATUS:

COVID VACCINATION a)Single dose b)Double dose c) Booster


STATUS:

GENERAL EXAMINATION TEMPERATURE: PULSE: BP: RR:


HEIGHT (cms): WEIGHT (kg): BMI:

SYSYTEMIC
EXAMINATION

DIAGNOSIS/SUMMARY
OF THE FINDINGS

MANAGEMENT

INVESTIGATIONS HEMOGLOBIN: URINE PROTEIN:

BLOOD SUGAR: URINE SUGAR:

BLOOD GROUP:

ADVICE GIVEN

FOLLOW UP
6) NAME: ………………………………………………Age/Sex………….. Date of Visit……………..

CHIEF COMPLAINTS

PAST HISTORY

PERSONAL HISTORY

TREATMENT HISTORY

IMMUNIZATION STATUS:

COVID VACCINATION a)Single dose b)Double dose c) Booster


STATUS:

GENERAL EXAMINATION TEMPERATURE: PULSE: BP: RR:


HEIGHT (cms): WEIGHT (kg): BMI:

SYSYTEMIC
EXAMINATION

DIAGNOSIS/SUMMARY
OF THE FINDINGS

MANAGEMENT

INVESTIGATIONS HEMOGLOBIN: URINE PROTEIN:

BLOOD SUGAR: URINE SUGAR:

BLOOD GROUP:

ADVICE GIVEN

FOLLOW UP

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