Chapter 1: Community Survey

A. General information
Description Details Description Details
Name of the locality Name of GP/Ward No

Name of the Block/ District

Borough
Nearest PHC/UPHC Distance from NRSMC
Subcentre Anganwadi Centre

Name of the ASHA Employed Since

B. Environmental Sanitation:
 Refuse disposal: Dumping / Municipal Vat / Others (specify..........................................)

 Frequency of refuse collection by municipal workers:

 Drainage facility : Kutcha / Pucca / Mixed / Absent/covered/open

 Water-logging : Present / Absent / Seasonal

 Source & mode of Water supply :

C. Demography of the Community

Total Population Sex Ratio
Birth Rate Death Rate
U-5 children Eligible couple

D. Area Map

Chapter 2: Family Identification (Family no.-1)

1
A. Identification:
Name of head of the family (HOF):_____________________________Type of family: Nuclear / Joint
Address:____________________________________________________________________________
Religion: ______________Caste: ___________Place of Origin:___________Length of stay:________
B. Particulars of the family members: Mother tongue:

Sl Names begin with

Marital Status

Physiological
Education
No

Aadhar No.
Occupation
Relation to
Head of the family

Physical
Activity
Gender

status
HOF

ACU
Age

Total adult consumption unit (ACU) of the family:

C. Socio-Economic Details:
 Total monthly income of the family: Rs. __________________________________
 Socio-economic Status __________________________________________________________
 Social Scheme Avail (Please tick/mention)
Swasthy Sathi Old Age pension Widow Pension Laxmir Bhandar
Others-
D. Monthly Expenditure
Sl No Item of expenditure Amount (INR) % total family income
1 Food
2 Electricity
3 Fuel
4 Transport
5 Education
6 Clothing
7 Out of pocket expenditure on health
8 Addiction
9 Others (specify)
Balance: Savings (S/B account/TD/LIC)/Debt
Chapter 3: Environmental details of the Family

2
 A. House Plan–preferably draw a rough sketch

B. Housing- Ownership: Own/ rented, Type: Pucca/Mixed

Set back area No. & area of living rooms
Wall & floor Per Capita Floor Space
Person per room Door & Window area
Ventilation Cross-ventilation
Sex separation Over crowding
Lighting Dampness
C. Kitchen - in a separate room / in living room / on verandah
Smoke Outlet Type of fuel used
Overall cleanliness Washing area
Storage of cooked Storage of raw food
food
Storage of salt/other things Kitchen garden
D. Water Supply: Mode of supply-continuous/intermittent

Attribute Drinking Other purpose

Source

Carriage

Storage

3
Adequacy

Special Treatment

E. Waste management-
 Solid-waste Disposal:
Container used Yes/ No; with lid/ without Lid; ssegregated/ non-segregated

Frequency of disposal: daily/alternate day/ weekly/ other Place of

disposal

 Excreta Disposal: Latrine

a. Ownership: Own/ Shared/ Community/ others (specify.......................................)
b. Type: Sanitary/Insanitary/pour flashed/syphon flushed
c. Disposal of child’s faecal matter:
d. Distance of toilet from dwelling place:
e. Number of user:
f. Maintenance: maintained/not maintained
g. Water supply: running/stored
h. Provision of artificial lighting: Present/ Absent
i. Hand washing facility (soap use): present/absent
F. i) Comments on Vector menace in the ssurroundings

ii) Pets/live-stocks- Present/Absent

iii) Kitchen garden: present/absent
G. Any social problem
Illiteracy Addiction -Cigarette /beedi, khaini, Specially able Chronically ill
betel leaves with zarda, alcohol member member

Unemployment Divorcee/separated/widow/widower Working mother Teenage Pregnancy

without any
caregiver
School drop Child Labour Others (specify)
out
H. Vital events in the family (during FAP)
Events Year
1st 2nd 3rd 4th
Births
Death
Marriage

4
Divorce/separation
Adoption
Chapter 4: Awareness and practice regarding locally endemic diseases
 Awareness & practice about locally endemic ccommunicable diseases
Disease/related Date of Knowledge Practice (what do Advice given
events visit (cause/MOT/Cardinal they do, care seeking
features/where to go) behaviour)

Diarrhoeal
disease

ARI

Malaria

5
 Dengue

Tuberculosis

Leprosy

HIV/AIDS

Animal bites

6
  Awareness & practices about non-communicable diseases
Disease Date Knowledge (risk factors, mode Practice (preventive & Advice given
of of presentation, where to go) promotive practices,
visit care seeking)
Hypertension

Diabetes

Anaemia

Cancers

IHD/Stroke

 Awareness & practices about health hygiene

Activities Date of Knowledge Practice Advice given
visit

7
Hand washing

Food &
environmental
hygiene

Personal
hygiene

Respiratory
hygiene

Genital
hygiene

 Awareness & practices about RMNCH+A

Activities Date of Knowledge Practice Advice given
visit
8
Infant/child care
practices(newborn
care/breast feeding/
immunization)
including availing
ICDS services+ JSY,
JSSK etc

Care Nutrition
during
adolesce Physical
nce health
Psychologi
cal health
Life skill

Reproduct
ive health
Care
during
adolesce
nce

Care
during
adolesce
nce

Pre-conceptional,
ante-natal (rest &
sleep/physical activity
/diet/hygiene/ANC-
services+ ICDS/
BPCR), and postnatal
care (care of the
9
 mother (hygiene/
early mobility/diet/
rest/care seeking for
complications)

Contraception &
family planning

Chapter 5: Dietary habit & Nutritional profile of the family

A. Dietary practices
a. Type of diet: Vegetarian/ Non-vegetarian
b. Vegetables washed thoroughly or merely rinsed in water– Yes/ No
c. Vegetables / Fruits cut: before washing/ after washing.
d. Cooking practice:
e. Iodised Salt (benefits/use/storage):
B-1. Nutritional status assessment done based on the average of three days’ consumption): Phase-I
Attributes Calorie Protein Iron Vit.-A Thiamin Riboflavin Vit.-C Fat Calciu
s (gm) (mg) (mcg) (mg) (mg) (mg) (gm) m(mg)
(Kcal)
Total daily
requirements
Total daily
consumption
Deficit/ Surplus
(% w.r.t. RDA)

B-2. Nutritional status assessment done based on the average of three days’ consumption): Phase-II
Attributes Calorie Protein Iron Vit.-A Thiamin Riboflavin Vit.-C Fat Calciu
10
 s (gm) (mg) (mcg) (mg) (mg) (mg) (gm) m(mg)
(Kcal)
Total daily
requirements
Total daily
consumption
Deficit/ Surplus
(% w.r.t. RDA)

B-3. Nutritional status assessment done based on the average of three days’ consumption): Phase-III
Attributes Calorie Protein Iron Vit.-A Thiamin Riboflavin Vit.-C Fat Calciu
s (gm) (mg) (mcg) (mg) (mg) (mg) (gm) m(mg)
(Kcal)
Total daily
requirements
Total daily
consumption
Deficit/ Surplus
(% w.r.t. RDA)

C. Nutritional advice
Phase (Date) Advice

Chapter 6: Individual Health Check up

Name: _________________________________________Age:_________Gender____________________
Substance Abuse/Addiction_____________________

Parameters Visit no. with date: Visit no. with date: Visit no. with Visit no. with
date: date:
H/o
Present
illness

11
H/o past
illness

Menstrual
&
Obstetric
history if
applicable

Weight (kg): , Height (m): , BMI (kg/sq m): , Pallor: Present/Absent

Icterus: Present/Absent, Oedema: Present/Absent, Clubbing: Present/Absent, Cyanosis: Present/Absent

Neck gland: Palpable/non-palpable, Neck vein: Engorged/ not- engorged, Temperature:

General survey

Respiration(rate):

Pulse: /minute (regular/irregular)

Blood Pressure:..............of Hg

Others important findings, if any:

Systemic
Examination

Any
laboratory
finding

Provisional
diagnosis

Management
Including
12
referral

Name: _________________________________________Age:_________Gender_______
Addiction_____________________ Any non communicable disease_________________

Parameters 1st Visit 2nd Visit 3rd Visit 4th Visit

Date: Date: Date: Date :
H/o Present
illness

H/o past
illness

Menstrual &
Obstetric
history if
applicable
Weight (kg): , Height (m): , BMI (kg/sq m): , Pallor: Present/Absent

Icterus: Present/Absent, Oedema: Present/Absent, Clubbing: Present/Absent, Cyanosis: Present/Absent

Neck gland: Palpable/non-palpable, Neck vein: Engorged/ not- engorged, Temperature:

General survey

Respiration(rate):

Pulse: /minute (regular/irregular)

Blood Pressure:..............of Hg

Others important findings, if any:

Systemic
Examination

13
Any laboratory
finding

Provisional
diagnosis
Management
Including
referral

Name: _________________________________________Age:_________Gender_______
Addiction_____________________ Any non communicable disease_________________

Parameters 1st Visit 2nd Visit 3rd Visit 4th Visit

Date: Date: Date: Date :
H/o Present
illness

H/o past illness

Menstrual &
Obstetric history
if applicable

Weight (kg): , Height (m): , BMI (kg/sq m): , Pallor: Present/Absent

Icterus: Present/Absent, Oedema: Present/Absent, Clubbing: Present/Absent, Cyanosis: Present/Absent

Neck gland: Palpable/non-palpable, Neck vein: Engorged/ not- engorged, Temperature:

General survey

Respiration(rate):

Pulse: /minute (regular/irregular)

Blood Pressure:..............of Hg

Others important findings, if any:

Systemic
Examination

14
Any laboratory
finding

Provisional
diagnosis
Management
Including
referral

Name: _________________________________________Age:_________Gender_______
Addiction_____________________ Any non communicable disease_________________

Parameters 1st Visit 2nd Visit 3rd Visit 4th Visit

Date: Date: Date: Date :
H/o Present
illness

H/o past illness

Menstrual &
Obstetric history
if applicable
Weight (kg): , Height (m): , BMI (kg/sq m): , Pallor: Present/Absent
Icterus: Present/Absent, Oedema: Present/Absent, Clubbing: Present/Absent, Cyanosis: Present/Absent
Neck gland: Palpable/non-palpable, Neck vein: Engorged/ not- engorged, Temperature:
General survey

Respiration(rate):
Pulse: /minute (regular/irregular)
Blood Pressure:..............of Hg
Others important findings, if any:

Systemic
Examination

15
Any laboratory
finding

Provisional
diagnosis
Management
Including
referral

Name: _________________________________________Age:_________Gender_______
Addiction_____________________ Any non communicable disease_________________

Parameters 1st Visit 2nd Visit 3rd Visit 4th Visit

Date: Date: Date: Date :
H/o Present
illness

H/o past illness

Menstrual &
Obstetric history
if applicable
Weight (kg): , Height (m): , BMI (kg/sq m): , Pallor: Present/Absent
Icterus: Present/Absent, Oedema: Present/Absent, Clubbing: Present/Absent, Cyanosis: Present/Absent
General survey

Neck gland: Palpable/non-palpable, Neck vein: Engorged/ not- engorged, Temperature:

Respiration(rate):
Pulse: /minute (regular/irregular)
Blood Pressure:..............of Hg
Others important findings, if any:

Systemic
Examination

16
Any laboratory
finding

Provisional
diagnosis

Management
Including
referral

Name: _________________________________________Age:_________Gender_______
Addiction_____________________ Any non communicable disease_________________

Parameters 1st Visit 2nd Visit 3rd Visit 4th Visit

Date: Date: Date: Date :
H/o Present
illness

H/o past illness

Menstrual &
Obstetric history
if applicable
Weight (kg): , Height (m): , BMI (kg/sq m): , Pallor: Present/Absent
Icterus: Present/Absent, Oedema: Present/Absent, Clubbing: Present/Absent, Cyanosis: Present/Absent
General survey

Neck gland: Palpable/non-palpable, Neck vein: Engorged/ not- engorged, Temperature:

Respiration(rate):
Pulse: /minute (regular/irregular)
Blood Pressure:..............of Hg
Others important findings, if any:

Systemic
Examination
17
Any laboratory
finding

Provisional
diagnosis

Management
Including
referral

Name: _________________________________________Age:_________Gender_______
Addiction_____________________ Any non communicable disease_________________

Parameters 1st Visit 2nd Visit 3rd Visit 4th Visit

Date: Date: Date: Date :
H/o Present
illness

H/o past illness

Menstrual &
Obstetric history
if applicable
Weight (kg): , Height (m): , BMI (kg/sq m):
Pallor: Present/Absent
General survey

Icterus: Present/Absent, Oedema: Present/Absent, Clubbing: Present/Absent, Cyanosis: Present/Absent

Neck gland: Palpable/non-palpable, Neck vein: Engorged/ not- engorged, Temperature:
Respiration(rate):
Pulse: /minute (regular/irregular)
Blood Pressure:..............of Hg
Others important findings, if any:
Systemic
Examination
18
Any laboratory
finding

Provisional
diagnosis

Management
Including
referral

Name: _________________________________________Age:_________Gender_______
Substance Abuse/Addiction_____________________ Any non communicable
disease_________________
Visit & Date:

Components Write up/findings

H/o Present
illness

H/o past illness

Menstrual &
Obstetric history
if applicable
19
 Weight (kg): , Height (m): , BMI (kg/sq m): , Pallor: Present/Absent
Icterus: Present/Absent, Oedema: Present/Absent, Clubbing: Present/Absent, Cyanosis: Present/Absent
Neck gland: Palpable/non-palpable, Neck vein: Engorged/ not- engorged, Temperature:
General survey

Respiration(rate):
Pulse: /minute (regular/irregular)
Blood Pressure:..............of Hg
Others important findings, if any:

Systemic
Examination

Any laboratory
finding

Provisional
diagnosis
Management
Including
referral

Chapter 7: Health Check up of under five child

Name: _________________________________________Age:_________Gender_______
Place of delivery :Home/ Institution. Type of delivery: Normal/ C.S./ Assisted.
Birth Wt. ___________
Any Congenital anomalies (specify): _______________________________________________________
Date of birth:_________________________ Delivered at: Pre-term/ Full term
 Feeding Practice (for child <1 year of age)
 Pre-lacteal feeding given: Yes/ No
 Time of initiation of breast feeding: Within 1 hr/ 1- 24 hrs/ 1-3 days/ > 3 days
 Frequency and mode of breast feeding:
 Exclusive breast feeding done: Yes/ No if yes, duration ________________

20
  Any artificial feeding before 6 months : Yes/ No
 Initiation and type of complementary feeding/feed:_____________________________
 Continuation of breast feeding in months: ________________________
 Current feeding practice (for all U-5):

 Feeding during illness(for all U-5):

 Attending AWC:

 Immunization of the child: Place of Vaccination: Govt/Private/Others (Specify)

 Mother & Child protection Card available: Yes/No
Vaccine Given at Age Vaccine Given at Age Vaccine Given at Age
BCG OPV- 0 Hep B (birth dose)
OPV- 1 Penta - 1 IPV-1
OPV- 2 Penta - 2 IPV-2
OPV- 3 Penta - 3
Rota- 1 Rota- 2 Rota- 3
MR- 1 JE-1 DPT booster
MR- 2 JE-2 DPT booster
PCV-1 PCV-2 PCV-3
OPV booster OPV booster
 Immunization Status:
 Vit A(in oil):
 IFA/Albendazole:
 Comment on the Growth & development of the Child: (refer to ICDS Growth chart)
Date Comments

21
  Comments on any problem in Developmental milestones:

 Examination of Child
Component Write up/findings
H/o Present
illness

H/o past illness

Family history
w.r.t. sibling

Weight(kg/gm):
Height(cm):
MUAC(cm):
Head /Chest circumference:
Pallor:
Icterus:
General survey

Oedema:
Clubbing:
Cyanosis:
Pulse:
Respiration:
Teeth:
Others any important finding:

Systemic
Examination

Any laboratory
22
finding

Provisional
diagnosis

Management
Including
referral

Chapter 7: Health Check up of under five child

Name: _________________________________________Age:_________Gender_______
Place of delivery :Home/ Institution. Type of delivery: Normal/ C.S./ Assisted.
Birth Wt. ___________
Any Congenital anomalies (specify): _______________________________________________________
Date of birth:_________________________ Delivered at: Pre-term/ Full term
 Feeding Practice (for child <1 year of age)
 Pre-lacteal feeding given: Yes/ No
 Time of initiation of breast feeding: Within 1 hr/ 1- 24 hrs/ 1-3 days/ > 3 days
 Frequency and mode of breast feeding:
 Exclusive breast feeding done: Yes/ No if yes, duration ________________
 Any artificial feeding before 6 months : Yes/ No
 Initiation and type of complementary feeding/feed:_____________________________
 Continuation of breast feeding in months: ________________________
 Current feeding practice (for all U-5):

 Feeding during illness(for all U-5):

 Attending AWC:

 Immunization of the child: Place of Vaccination: Govt/Private/Others (Specify)

 Mother & Child protection Card available: Yes/No
Vaccine Given at Age Vaccine Given at Age Vaccine Given at Age
BCG OPV- 0 Hep B (birth dose)
OPV- 1 Penta - 1 IPV-1
OPV- 2 Penta - 2 IPV-2
OPV- 3 Penta - 3
Rota- 1 Rota- 2 Rota- 3
MR- 1 JE-1 DPT booster
MR- 2 JE-2 DPT booster
PCV-1 PCV-2 PCV-3
OPV booster OPV booster
 Immunization Status:
 Vit A(in oil):
23
  IFA/Albendazole:
 Comment on the Growth & development of the Child: (refer to ICDS Growth chart)
Date Comments

 Comments on any problem in Developmental milestones:

 Examination of Child
Component Write up/findings
H/o Present
illness

H/o past illness

Family history
w.r.t. sibling

24
 Weight(kg/gm):
Height(cm):
MUAC(cm):
Head /Chest circumference:
Pallor:
Icterus:
General survey

Oedema:
Clubbing:
Cyanosis:
Pulse:
Respiration:
Teeth:
Others any important finding:

Systemic
Examination

Any laboratory
finding

Provisional
diagnosis
Management
Including
referral

Chapter 7: Health Check up of under five child

Name: _________________________________________Age:_________Gender_______
Place of delivery :Home/ Institution. Type of delivery: Normal/ C.S./ Assisted.
Birth Wt. ___________
Any Congenital anomalies (specify): _______________________________________________________
Date of birth:_________________________ Delivered at: Pre-term/ Full term
 Feeding Practice (for child <1 year of age)
 Pre-lacteal feeding given: Yes/ No
 Time of initiation of breast feeding: Within 1 hr/ 1- 24 hrs/ 1-3 days/ > 3 days
25
  Frequency and mode of breast feeding:
 Exclusive breast feeding done: Yes/ No if yes, duration ________________
 Any artificial feeding before 6 months : Yes/ No
 Initiation and type of complementary feeding/feed:_____________________________
 Continuation of breast feeding in months: ________________________
 Current feeding practice (for all U-5):

 Feeding during illness(for all U-5):

 Attending AWC:

 Immunization of the child: Place of Vaccination: Govt/Private/Others (Specify)

 Mother & Child protection Card available: Yes/No
Vaccine Given at Age Vaccine Given at Age Vaccine Given at Age
BCG OPV- 0 Hep B (birth dose)
OPV- 1 Penta - 1 IPV-1
OPV- 2 Penta - 2 IPV-2
OPV- 3 Penta - 3
Rota- 1 Rota- 2 Rota- 3
MR- 1 JE-1 DPT booster
MR- 2 JE-2 DPT booster
PCV-1 PCV-2 PCV-3
OPV booster OPV booster
 Immunization Status:
 Vit A(in oil):
 IFA/Albendazole:
 Comment on the Growth & development of the Child: (refer to ICDS Growth chart)
Date Comments

26
  Comments on any problem in Developmental milestones:

 Examination of Child
Component Write up/findings
H/o Present
illness

H/o past illness

Family history
w.r.t. sibling

Weight(kg/gm):
Height(cm):
MUAC(cm):
Head /Chest circumference:
Pallor:
Icterus:
General survey

Oedema:
Clubbing:
Cyanosis:
Pulse:
Respiration:
Teeth:
Others any important finding:

Systemic
Examination

27
 Any laboratory
finding

Provisional
diagnosis
Management
Including
referral

Chapter 8: Health Check-up of Ante natal / Post-natal women

Name: ____________________________________________Age:__________ Married for____________
Addiction_________________________ Any non-communicable disease__________________________
LMP_______________ EDD_______________ Gravida _______Parity:__________
Td toxoid: 1st dose/ Booster __________________________ 2nd dose ________________________
 Obstetric History:
Order of Age at Outcome: Live Type of Place of Conducted Complications, if H/o ANC/INC/ PNC
pregnan pregna birth/ Still birth/ delivery delivery by any
cy ncy Abortion

 Attending AWC:
 Availing MCH schemes:
 History and Clinical examination
Component Write up/findings
H/o present illness

H/o past illness

Any risk factor

for pregnancy

28
Gestational period
(weeks)
Status of ANC
visit & services

Weight (kg): , Height (m): , Weight gain since 1st ANC:

Pallor: Present/Absent

Icterus: Present/Absent, Oedema: Present/Absent, Clubbing: Present/Absent, Cyanosis: Present/Absent

Neck gland: Palpable/non-palpable, Neck vein: Engorged/ not- engorged, Temperature:

Respiration(rate):
General survey

Pulse: /minute (regular/irregular)

Blood Pressure:..............of Hg

Others important findings, if any:

Fundal height(wks): , Lie:

Presentation: FHS:

Others any important finding:

Systemic
Examination

Any laboratory
finding
Hb%, Blood
Sugar, HIV,
HbsAg. VDRL,
Blood grouping &
typing, USG,
Thalassemia
screen, Urine R/E
& M/E etc
PostNatal Check-
up including
Neonatal Care &
Family Planning

29
 Provisional
diagnosis

Management/
advice
Including referral

Chapter 8: Health Check up of Ante natal / Post-natal women

Name: ____________________________________________Age:__________ Married for____________
Addiction_________________________ Any non-communicable disease__________________________
LMP_______________ EDD_______________ Gravida _______Parity:__________
Td toxoid: 1st dose/ Booster __________________________ 2nd dose ________________________
 Obstetric History:
Order of Age at Outcome: Live Type of Place of Conducted Complications, if H/o ANC/INC/ PNC
pregnan pregna birth/ Still birth/ delivery delivery by any
cy ncy Abortion

 History and Clinical examination

Component Write up/findings
H/o present illness

H/o past illness

30
Any risk factor
for pregnancy

Gestational period
(weeks)
Status of ANC
visit & services

Weight (kg): , Height (m): , BMI (kg/sq m): , Pallor: Present/Absent

Icterus: Present/Absent, Oedema: Present/Absent, Clubbing: Present/Absent, Cyanosis: Present/Absent

Neck gland: Palpable/non-palpable, Neck vein: Engorged/ not- engorged, Temperature:

Respiration(rate):

Pulse: /minute (regular/irregular)

General survey

Blood Pressure:..............of Hg

Others important findings, if any:

Fundal height(wks): , Lie:

Presentation:

Others any important finding:

Systemic
Examination

Any laboratory
finding
Hb%, Sugar,
HIV, HCV,
VDRL, Blood
group, etc

Provisional
diagnosis

31
Management/
advice
Including referral

Chapter 9: Action taken and recommendation made at each visit

Chapter 10 : Summary after each phase

32
Chapter 11. Report of Family adoption programme

33
34
“To put the world right in order, we must first put the nation in order; to put the

nation in order, we must first put the family in order; to put the family in order,

we must first cultivate our personal life; we must first set our hearts right.” »

Confucius

35