Question:

In your adopted families identify points mention in competencies 2.1, 2.2 and 2.3.Mention the
details in your Family Adoption Folder record copy.

Family Folder Sample Format:

A. General Information:

House no.: Setting: urban/rural

Name of village/ward: Sub-centre/HWC PHC/CPHC/UHC

1. Head of the Family:

Name: Age: Sex:

Religion: Caste: Occupation:

Education:

2. Type of family: Nuclear/Joint

3. Total number of family members:

4. Family Profile:

Sl. Name of the Age Sex Relationship Marital Education Occupation Income Health
No. Family Member with Head of Status status
the Family
1

6
 4. Socio Economic Status of Family:

Per capita monthly income of the family = Total family income =

Total family members

Socio Economic Status (Modified B G Prasad Classification, 2022) = ________________

5. Draw the family tree:

6. Any of the following persons present:

Sl. Category of person Number of such persons Specific details of one

no. such person (Yes/ No)

1 Pregnant Women

2 Lactating Women

3 Under 5 Children

4 Adolescent (10-19 years)

5 Women of reproductive age-group (15-45 years)

6 Geriatric (above 60 years)

7 Diabetes/Stroke/Cardiovascular Disease/Cancer
7. Living environment:

Questions Options Observation/ Description Interpretation

1. Housing
Types of house 1. Pucca
2. Kutcha
3. Semipucca

Setback
1.Adequate
Ventilation 2.Inadequate

Lighting

Electricity
1. Present
Noise pollution 2. Absent

Overcrowding *
*mention according to
which criteria
2. Kitchen
Location 1. Separate
2. Attached to living
room
Fuel used 1. LPG
2. Smokeless chulha
3. Firewood
4. Others
Ventilation
1.Adequate
2.Inadequate
Lighting

Indoor air 1. Present

pollution 2. Absent
3. Water supply
Sources of water 1. Improved
2. Unimproved
Distance from the In meters _____meters
nearest septic tank
Area around the 1. Satisfactory Platform-
source 2.Unsatisfactory Drainage system-
Storage of water 1. Covered
2. Uncovered
Water treatment 1. Boiling
prior to drinking 2. Use alum
3.Add bleach/chlorine
4. Strain through cloth
 5. Ceramic, sand or other
filter
6. Electric purifier
7. Allow to stand and
settle
8. Other
9. No treatment
4. Refuse disposal
Method 1. Composting Solid waste: Sanitary/Insanitary
2. Burning
3. Open dumping
4. Handed over to Liquid waste:
municipality
5. Other
6. Excreta disposal
Type of latrine 1. Water sealed
2. Non water sealed
Running water 1. Present
facility 2. Absent
Condition of 1. Satisfactory
latrine (platform 2. Unsatisfactory
and surrounding)
Septic tank 1. Covered
2. Uncovered
7. Biological environment
Livestock/ Poultry 1. Yes
kept in premises 2. No
Maintenance and 1. Sanitary
housing of 2. Insanitary
livestock
Breeding places
for mosquitoes and 1. Yes
flies 2. No
Rats and rodents

8. Social environment
Any
unemployment
Any addiction 1.Yes
2.No
Any handicapped

Any out of school

students
8. Pregnant women (Record only one):

Name and age:

Husband’s name:

History Physical Examination ANC card record

Last menstrual period: Weight(kg): Total ANC visit:
Height(m): Place of ANC care:
Expected date of delivery: BMI: No. of Folic acid consumed:
Pallor: No. of IFA consumed:
No. of pregnancy: Pedal oedema: No. of Calcium consumed:
BP: PR: No. of Td vaccine received:

9. Lactating Women (Record only One):

Name and age:

Husband’s name:

History Physical Examination Post natal service received

Type of delivery: Weight(kg): Total postnatal visit by ASHA:
Place of delivery: Height(m): No. of IFA consumed:
Initiation of breastfeeding: BMI: No. of Calcium consumed:
____hrs after birth Pallor:
Colostrum feeding: Pedal oedema:
Prelacteal given: BP:
Practicing EBF: PR:

10. Under 5 child (Record Youngest Under 5 Child of family):

History Physical Examination

Birth Preterm/ Term Age in months:
Birth weight: ___________gms Weight(kg): __________kg
Place of delivery: Home/Institute Height/length(cm): __________cm
Initiation of _____hours after MUAC: __________cm
breastfeeding birth
Colostrum feeding: Yes/ No Weight for age: Normal/Underweight/
Severely underweight
Prelacteal given: Yes/ No Height for age: Normal/ Stunted/
Severely stunted
Frequency of __________/day Weight for Height: Normal/ Wasted/
feeding(including night Severely wasted
feeding)
Urine frequency __________/day Immunization history
Complementary feeding Yes/ No Fully immunized(FIC)/
started Partially immunized(PI)/
a. Age of staring of CF ________months Non immunized (NI)
b. Continuing Breast Vaccines due in next visit:
feeding
c. Frequency of feeding: Vit A prophylaxis received: _________doses
 Yes/ No
d. Hand washing
practice

11. Details of Adolescent if available (Record Youngest adolescent of family):

Questions Answers
Name
Age __________years
Sex Male/ Female
Anthropometric measurements

Whether going to school: Yes/ No

If no Reason for not going?
Performance in school
Extracurricular/ recreational activities
Any abuse/violence
What are the health problems currently experiencing?
For girls:
Age of menarche _________years
Menstrual history Cycle_________ Duration of
flow_________
Whether use of sanitary pad/ clothes?
Frequency of changing pads
Disposal of pads

12. Women of reproductive age-group (15-45 years)(only one):

Questions Answers
Name
Age __________years
Anthropometric measurements Weight(kg):
Height(m):
BMI:
Physical Examination Pallor:
Pedal oedema:
BP:
PR:
What are the health problems currently experiencing?
Age of menarche _________years
Menstrual history Cycle_________ Duration of
flow_________
Whether use of sanitary pad/ clothes?
Frequency of changing pads
Disposal of pads
Last menstrual period
13. Geriatric Person (only one):

Questions Answer
Name
Age __________years
Sex Male/ Female
What are the health problems you
currently experiencing?
How do you feel currently?

14. Diabetes/Stroke/Cardiovascular Disease/Cancer:

Questions Answer
Name
Age __________years
Sex Male/ Female
Anthropometric measurements

Type of NCD suffering from: 1. Diabetes 2. Cardiovascular Disease 3. Stroke

4. Cancer
Duration since diagnosis ________years
Whether taking medications for the NCD Yes/ No
regularly as advised by Doctor?
If no reasons: 1. Lack of money 2. Lack of doctors/ health
facility 3. Lack of motivation /awareness
4. Others, specify_________________________
Whether going for follow-up for NCD with Yes/ No
doctors/ health facility?
If no reasons: 1. Lack of money 2. Lack of doctors/ health
facility 3. Lack of motivation /awareness
4. Others, specify_________________________

15. 24 hours dietary history of the family:

Meal Food items (in grams) Raw ingredient (in Any leftover food not consumed
grams) during same day (in grams)
Breakfast

Snacks

Lunch

Snacks
 Dinner

Outside
food

16. Problems in the family:

Health needs perceived by the family: Health needs perceived by you:

Environment related:
1. 1.
2. 2.
3. 3.

Family members related:

1. 1.
2. 2.
3. 3.

Nutrition related

Any other problems:

17. Comprehensive diagnosis:

 18. Health advices to the family:

Preventive:
1.

2.

3.

Promotive:
1.

2.

3.

Curative:
1.

2.

3.

Rehabilitative:
1.

2.

3.

Any other (e.g., Vocational):