Fap Proforma
Fap Proforma
Fap Proforma
Complete Address:
FAMILY STRUCTURE
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
2. Indiscriminate spitting in
and around the house
3. Addictions:
Alcohol
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
Meal pattern: Bed tea, Breakfast, Mid-morning Lunch, Evening tea, Dinner, bedtime drink.
Particulars Inference
Prevention of Common
diseases
Family planning
services
Psychiatric condition
Environmental
protection
Examine and interview all the family members present during your visit. Briefly summarize the
findings.
CHIEF COMPLAINTS
PAST HISTORY
PERSONAL HISTORY
TREATMENT HISTORY
IMMUNIZATION STATUS:
SYSYTEMIC
EXAMINATION
DIAGNOSIS/SUMMARY
OF THE FINDINGS
MANAGEMENT
BLOOD GROUP:
ADVICE GIVEN
FOLLOW UP
2) NAME: ………………………………………………Age/Sex………….. Date of Visit……………..
CHIEF COMPLAINTS
PAST HISTORY
PERSONAL HISTORY
TREATMENT HISTORY
IMMUNIZATION STATUS:
SYSYTEMIC
EXAMINATION
DIAGNOSIS/SUMMARY
OF THE FINDINGS
MANAGEMENT
BLOOD GROUP:
ADVICE GIVEN
FOLLOW UP
3) NAME: ………………………………………………Age/Sex………….. Date of Visit……………..
CHIEF COMPLAINTS
PAST HISTORY
PERSONAL HISTORY
TREATMENT HISTORY
IMMUNIZATION STATUS:
SYSYTEMIC
EXAMINATION
DIAGNOSIS/SUMMARY
OF THE FINDINGS
MANAGEMENT
BLOOD GROUP:
ADVICE GIVEN
FOLLOW UP
4) NAME: ………………………………………………Age/Sex………….. Date of Visit……………..
CHIEF COMPLAINTS
PAST HISTORY
PERSONAL HISTORY
TREATMENT HISTORY
IMMUNIZATION STATUS:
SYSYTEMIC
EXAMINATION
DIAGNOSIS/SUMMARY
OF THE FINDINGS
MANAGEMENT
BLOOD GROUP:
ADVICE GIVEN
FOLLOW UP
5) NAME: ………………………………………………Age/Sex………….. Date of Visit……………..
CHIEF COMPLAINTS
PAST HISTORY
PERSONAL HISTORY
TREATMENT HISTORY
IMMUNIZATION STATUS:
SYSYTEMIC
EXAMINATION
DIAGNOSIS/SUMMARY
OF THE FINDINGS
MANAGEMENT
BLOOD GROUP:
ADVICE GIVEN
FOLLOW UP
6) NAME: ………………………………………………Age/Sex………….. Date of Visit……………..
CHIEF COMPLAINTS
PAST HISTORY
PERSONAL HISTORY
TREATMENT HISTORY
IMMUNIZATION STATUS:
SYSYTEMIC
EXAMINATION
DIAGNOSIS/SUMMARY
OF THE FINDINGS
MANAGEMENT
BLOOD GROUP:
ADVICE GIVEN
FOLLOW UP