Field Record

Department of Community Medicine

Bhima Bhoi Medical College

Balangir

Name:___________________________________________
Roll No:__________________________________________
Year of admission:_________________________________

Signature of Teacher Signature of Student

Completion certificate
Sl Content Page no Signature of the Signature of the
No Student Teacher
Sl Content Page no Signature of the Signature of the
No Student Teacher
 1. Know your community
Urban Health & Training centre(UHTC) of Department of Community Medicine
(Kandhpallipada)
1.1Method of collection of information from the community-

1.2 Types of information to be collected:

Demographic characteristics
• Morbidity and mortality
• Socioeconomic factors
• Physical environment factors
• Available resources and utilization of health services
• Health problems felt by the community

1.3 Draw the map of the field practice area of UHTC

1.4 Schedule for obtaining basic background information about the community
1.Total no. of Sahis 2.Total no of households
3.Demographic characteristics:
4.Total population: ________________ 5. Total number of families:__________
6.Average family member:_____________7. Density of the population:________________
8. Total number of families on the basis of:
a. Religion:____________________
b. Caste:___________________
c. Language:__________________
9. Population distribution according to age and sex:
Age( in years) Male Female Total
<1

1-4

5-14

15-44
45-59

>60

TOTAL

10.Age Pyramid of community:

:
11.Total no. of women in reproductive age group :
12.Total no. f eligible couple :

13. Sex Ratio:

14.Education (Sex-wise, literate and illiterate)

15. Occupation (major occupation, unemployment, etc)

1.5 Morbidity and mortality data:

Source of Data:-
[Use health care providers’ records/survey records, etc. Also discuss with community leaders
and member to identify why beneficiaries are not using preventive services to the extent they
should.]
1.Number of live births in last 1 year:
2. Common place of delivery:
3.Number of deaths in last 1 year:
4. Cause of Death in different groups in last year in the locality
Number Causes
Infant deaths
Maternal deaths
Other deaths

5. Common morbid conditions and nutritional deficiency disorders:

1.6.Utilization of preventive services:

1.. Immunization coverage

2.. Growth monitoring

3..Supplementary nutrition

4. Antenatal coverage

5. Family planning practices

1.7 Environmental characteristics:

1. Accessibility to the community ( Road Condition):-
2..Information regarding drinking water :
1.Source of drinking water:- Public well/ Public tube well/ Public Tap/ Pond
2.House hold having own water supply 1. Well
2.Deep Tube- well
3.Municipality Water Supply

3.Refuse Disposal of the Community

Public Bins for collection of waste- Yes/ No
Toilet facilities: Open / Community latrines / Private latrines
Collection and removal of liquid waste and drainage facilities

1.8 Available resources:

1.Organizations (names of youth club, mahila mandal,etc )

2. Educational Facilities (like school, college, Public Library)

3. Recreational Facilities (like playground, children parks, library, community hall, etc
4. Health Facilities- health centre, AWC, Polyclinic
1.No. of AWCs:- 2.No. of ASHAs Posted :
3.Institutions providing health care:a. Government ( Number & Type) b. Private ( Number &
Type)
c. Any other ( Number & Type)
5.Places of Religious Belief:-
6..NGOs working in the area
7.Public distribution system

8. Communication facilities available in the community

1.9.Substance abuse:
What are the common addictions in the community:
Smoking / Chewing tobacco ( khaini, jarda ,etc.) / Alcohol / Ganja / Drugs
Others (specify):
1.10. Health problems as felt by the community:
[Discuss with community decision makers and members and comment on the
following]

1. What population group (children, adult workers, etc.) are of greatest concern and
why ?
 2. What specific health problems are of most concern and why ?

3. What are the other health related concerns of the community

Service is not available in certain areas / Clinic hours are inconvenient to some people /
Community would like to have other additional services or manpower / others (specify)

3. How community feels about health services that are currently available (Include
also perception about other government and private health services available in the
area)

1.11Transect Walk Diagram

 1.12 Identify the salient findings of the community, after reviewing all the information
available under different headings
[Group the problems under different headings e.g. communicable disease problem,
nutritional problem, environmental sanitation problem, medical care problem,
population problem, Social Problem ]

Signature of Teacher Signature of Student

 2.Hospital services in UHTC
You should know what are the services provided at the UHTC (Kandhapallipada) and
whether they are free or paid.

Signature of Teacher Signature of Student

3.‘’Biomedical’’ Waste Disposal of UHTC (Kandhapallipada)
The waste produced in the course of health care activities carries a higher potential for
infection and injury than any other type of waste. Therefore it is essential to have safe and
reliable method for its handling. Inadequate and inappropriate handling of health care waste
may have serious public health consequences and a significant impact on the environment.
Give a brief report on the Bio Medical Waste disposal of the UHTC.

Signature of Teacher Signature of Student

 5.Family Study
5.1 GENERAL INFORMATION

Name of Head of the Family ......................................................................... Date ........................

Name of the person interviewed and his/her relation to the head of the family

Religion ......................... Caste ...................... Ward No. ............................. Sahi ..........................

Type of family : Nuclear / Joint / Extended House Hold No. .....................
Total no. of family members.....................................................
Duration of stay at this address:

5.2 . Family Information : ( Presently staying with family)

Com
Relation
Sl. Educatio Marrita Addict ments
Name to the Age Sex Occupation Income
No. n l Status ion /Rem
Head
arks

5.3 Family Tree:

5.4

5.5 Socioeconomic status: Assessment of socioeconomic status by Modified

kuppuswamy scale

1.Weightage of different items in Kuppuswamy Scale for determining

socioeconomic status of urban families:

Sl no Items Weightage
1 Education of the head of the household Professional degree, post- 7
graduate and above
Bachelor’s degree
6Intermediate or post –high
 school diploma
High school certificate
Middle school completion
Primary school completion
literate
Illiterate
2 .Occupation of the head of the Professional10 6
household (last occupation if retired) Semi-professional
Clerk, shop-owner, farm-
owner
Skilled worker
Unskilled worker
Unemployed
3 Family income per month(in Rs) 36,997 or above 7

12 18,498-36,996
13874-18,497

6 9249-13873
5547-9249
1866-5546
Less than equal to 1865

2.Monthly Income of Family

Total Income
Total Expenditure
Balance
Total no. of
Earning members

Total number of
Dependents

Savings
Debts

3.Monthly expenditure of the family

Item Expenditure Percentage

Food
Fuel
 Clothing
Education

Private Tution

Electricity

Substance
abuse

Housing (rent,
maintenance,
tax)

Social functions
(marriage,
festivals, etc)

Health and
illness

Travel/transport

Recreation
Any other
expenditure

Total

4.Pie Diagram of Expenditure of the family

5.Vital events in the family in the past 1 year

Births/ Deaths/ Marriage/ Migration

6.Health care utilization

 Availability, Accessibility, Affordability and Utilization of Health Services for
common/simple and complicated problems.
  Also make a note of Anganwadi, PDS, Government school which the family
accesses

 Why do they go to this particular physician (Traditional/ ISM/ Allopathic/

Quack)?

7.What are the transport facilities available to the family? During a health emergency do
they have an access to some form of transport facility?

8.Recreation facilities:Mobile/ Radio/ TV/ Magazine/ Cinema/Drama others.

9.How does the family get information/news:

Newspaper/Radio/Television/Telephone/Mobile/Computer/Others (specify)

10 How do they pass their free time

11..Assessment of social Problems:

1.Any Unemployed member in the family

2.Substance abuse( type, who uses,amout, frequency, duration,cost incurred)

3.Any mother who is unmarried, divorced or abandoned by husband’s family

4.Any handicapped or chronically ill family member

5.Any children above 5 years not going to school, if yes, reason

6.Is the mother working anywhere? If so, who looks after the child in her absence

7.Child Labour

8.Others (please specify)

5.2Study of Environment and Housing of the Family

A. Macro environment
 a. Draw a map of the area as you enter the area
b. Locate the house in the community

C. Environmental Information :
1. HOUSE INFROMATION
Housing:
Site : elevated/not elevated Location

Approach Road: narrow /not narrow

Ownership : own / rented / free

Draw the sketch map of the House.

B. Micro environment
a. Housing
 Type of the house
 a. Attached/Detached
b. Pucca/ Kacchha/ semipucca/ semikacchha
c. Owned/Rented/Leased out
 House Plan – preferably draw a rough sketch (at window level)

 Size of the house

a. Floor space of the house
b. Per capita space in the house
 Number of living rooms
 Other rooms
 Overcrowding: (Assessment of overcrowding)
Number of living rooms-
Total area of the living rooms (floor space-
Per unit floor space
Person per room

Sex Separation:
Comment on overcrowding
 Is floor flooded during rains
2. Assessment of ventilation

Ratio of the window space to the floor area 1/5th of the floor area: Yes/ No

Combined Windows & door space area/total floor 2/5th of the Floor area: Yes / No
space area-
Cross-ventilation: present / absent
Any other important finding

3.Lighting- Adequate/ Inadequate

4. Electricity present -

5.Kitchen
 Separate/Attached
 Platform: present/absent
 Platform used for cooking or not?
 Fuel used for cooking
(If fuel is used for cooking is kerosene then ask details about it)
 Smoke vent: present/absent
  Smokeless chullha
 Washing area for utensils
 Storage of cooked food, raw food items including vegetables

6.Water (for drinking purposes and for other purposes)

1. Source (mention all the different sources and preferably its use): Piped or un-
piped; Bore water/ Open well/ Hand pump/ River/ Tank/ any other. Also mention
the distance of source of water.
2. Collection and storage methods including frequency, method of collection,
method of transport, storage of water
3. Purification methods
4. Utilization of water: filter, drum, tumbler with or without a handle,

{Also know the following: Is the source of water safe?

Is it protected from pollution?

Is it protected from unauthorized access to human /animals?

If possible assess the source of water}

7.Sanitation
1.Describe the bathing area – anything identified which could be detrimental to the
health of the family members

2.Defecation
 Toilet facilities: If yes, is it attached to the house?-
 Does the toilet have soap and water?
 Public/ Community toilets; If available
o utilized or not
o are they sufficient
o are children encouraged to use these toilets
o are they allowed or encouraged to defecate/ micturate
near the house
 How far are these toilets located from dwelling unit
 Are they well maintained, water available, lighting available in
the toilets
 Type of latrine: Flushable/ water seal present/ Connected to a
septic tank/ Pit/ others/ municipal sewerage system
 Hand washing practices: with soap/ without soap/ with ash/ with
clay/ with mud/ only water.
 Before eating, before feeding the infant/child, before collecting
water for drinking from the vessel, after defecation and after
washing the bottom of the new born/infant/child
 Is the Toilet used by all the adults in the family : Yes / No
  If no, why do they go ?
 Do the children use it ?
 Where do you dispose child’s stool?

3a.Disposal of wastes (solid/ liquid/ sullage/ sewage/ garbage and refuse disposal)
 throw indiscriminately
 common pit
 burning
 composting
 municipal service
b.Segregation of wastes in to bio degradable and non bio degradable
 Waste containers in the house: Lid/No lid
 Where do they deposit the waste generated at home?
 Is a common waste container provided for the locality/street etc?
 How far is it located from house?
 How frequently is the waste collected from here
 Describe the common waste collection point/container/access to animals etc.
 Sullage disposal?
 How are used sanitary napkins/ Pads disposed
 How is the kitchen waste disposed- solid
4.Comment on breeding places of mosquitoes:
5. Fly nuisance: present / absent
6. Rodent Nuisance: present/Absent
7. Domestic pets/birds in the house: Present/ absent

If present Type : Cattle / Poultry / Cat / Dog

Do they have any separate shed for animals : Yes/No

Are there any cracks or crevices or rat holes in the house ?

Cooking and food handling practices
 Vegetables washed thoroughly and not merely rinsed in water
 Storage of vegetables/ perishables and not perishables
 Cooked food consumption/ storage / reheating etc.
 Cleaning of kitchen utensils and inspection of few of the commonly
used vessels for cooking and serving, to ascertain the cleanliness
of the vessels.
 Inspect the utensils used for infant feeding (including feeding bottle
for cleanliness/smell/and grease.

CULTURAL PRACTICES OF THE FAMILY

Note down the specific cultural practices prevalent in the family such as:
1. Withholding food items during antenatal period
2. Delivery at home itself
3. Pre lacteal feeds
4. Withholding colostrum
5. Application on the umbilical cord
6. Branding

Summary -

Problems identified
Environmental

Health

Social

Suggestions to solve the problem

Individual level

Family level

Community level

Signature of teacher Signature of student

Lesson 5: Family’s knowledge and practice on common health problems and utilization
of health services
5. Knowledge about common diseases
5. Knowledge regarding causation, modes of transmission, prevention and care seeking
behaviour with respect to the following communicable diseases:
[Discuss with adult family members and comment on the following]
Disease (Ever Causation/ Mode of Care Seeking
Heard Y/N) Transmission prevention Behavior a. Past
b. Future

Diarrhoea

Pneumonia/
cough and cold

Malaria
Dengue
Tuberculosis
AIDS/STD

Others

5.4. Knowledge regarding causation, risk factors, prevention and care seeking behaviour with
respect to the following non communicable diseases:
Disease (Ever Heard Risk factors Mode of prevention Care Seeking
Y/N) Behavior

Hypertension

Diabetes
Cancer

Heart Disease and

stroke

5.5 Visits to Health Facilities:

a.For minor ailments: private/Govt/others (for eg: medicine shop,NGO) (specify)

b.For major ailments: private/Govt/others(for eg: medicine shop,NGO) (specify)

c. For antenatal,natal and post natal care: private/Govt/others (for eg:quack

practitioners,dai,NGOs) (specify)

d.For preventive services(immunisation, family planning etc) private/Govt/others(for eg:

medicine shop,NGO) (specify)

e. Which system is preferrableto the family: Allopathy/AYUSH/both(specify)

f. If health facilities not visited regularly, reasons

5.5.3 Knowledge and practice about personal hygeine

Personal hygeine measures Knowledge Practice
Hand washing Technique
When
With
what

Brushing teeth Frequency

With what
Bathing
Nail
Hair
Menstrual hygeine What is
used

Nutritional profile of the family & individual family members

At the end of this lesson you should be able to:

Understand the importance and practice of different methods applied to nutritional assessment.
Carry out dietary survey, anthropometric measurements as well as clinical assessment of nutritional
deficiency disorders. Analyze types and amounts of food consumed by the family. Calculate the
nutrient intake of the family (calorie, proteins, vitamins, iron, etc.) Identify the types of nutritional
deficiencies prevalent in the family and the underlying factors responsible for these. Suggest measures
to improve the quality of food and existing dietary patterns of the family.

The nutritional assessment of the community can be carried out using the
following methods:
1.In Field:-a. Clinical examination for nutritional deficiency signs.
b. Anthropometry or body measurements.
c. Diet surveys.
2. In Laboratory-d. Biochemical tests.
3. From record e. Vital statistics such as mortality and morbidity rates.

DIETARY PRACTICES
a. Type of diet – Vegetarian/Non vegetarian
 b. Staple diet – Rice/Ragi/Wheat/Maize
c. Procurement of raw food: Cereals, vegetables, fruits and groceries
d. Calculate the consumption units for the family
e. Method used for dietary survey: Stock Inventory method/ 24 hr dietary
recall
f. Dietary co efficient is defined as the energy requirement of an adult male
sedentary worker i.e. 1 D C = 1 adult consumption unit = 2400 kcal
(ICMR Recommendation)

g.

Energy
Category Type of work Dietary Co efficient
Requirement
Adult Male sedentary worker 1.0 2400
moderate worker 1.2 2800
heavy worker 1.6 3900
sedentary worker 0.8 1900
Adult female moderate worker 0.9 2200
heavy worker 1.2 2800
Adolescents 12 – 21 yrs 1.0 2400
10 – 11 yrs 0.8 1900
8 – 9 yrs 0.7 1700
6 – 7 yrs 0.6 1440
Children
4 – 5 yrs 0.5 1200
1 – 3 yrs 0.4 1000
< 1 yr 0.3

h. For one consumption unit the following is the balanced diet prescribed

Cereals 460 g
Pulses 40 g
 Green Leafy vegetables 40 g
Other vegetables 60 g
Roots and tubers 50 g
Milk 150 g
Fat/Oil/Ghee 40 g
Sugar/ Jaggery 30 g

 Estimate the amount of food items used by the family per day.

 Estimate the amount they should actually be using according to the

RDA

 Then compare the above two and calculate the deficiency or excess;
and comment

 Also calculate the energy and protein deficiency or excess for the
entire family
i.e. 2400 k cal per consumption unit (+ 300 kcal for pregnancy; +
550 kcal for the first 6 months of lactation; + 400 kcal for 6 – 12
months of lactation)
AND protein of 1 g/kg of body weight
Table 6.1 Dietary Intake of the family (food group wise)
Food groups Food items Individual Itemwise Total Quantity (food group
quantity [gm/ml] wise)

CEREALS
PULSES
GREEN LEAFY VEGETABLES
(specify)

ROOTS AND TUBERS

(specify)

OTHER VEGETABLES
(specify)

FRUITS (specify)

MILK & MILK PRODUCTS

(specify)

FLESH FOODS
INCLUDING MILK

FATS & OILS (specify)

SUGAR & JAGGERY

NUTS & OILSEEDS

SPICES & CONDIMENTS

MISCELLANEOUS (specify)

Table 6.2 Dietary Intake of the family (nutrient wise)

Foodstuff Quantity Calories Protein Iron (mg) Vit A (µg) Thiami n Riboflavi Vit C (mg)
(gm/ml) (Kcal) (gm) (mg) n (mg)
 Total
consumption

Table 6.3: Dietary requirement of the family and the balance (Food group wise)

Ag Se Type Physiologi Food Group Amount requirement according to balanced diet

Sl e x of cal Status
n Wor
o k

Cereals and Pulses Gree Root Other Fruits Milk Fats Sugar
Millets and n s Vegetables and and and
flesh Leafy and milk oils jagge
foods Vege tube prod ry
table rs ucts
s

Total requirement

Total Consumed

Balance %
Table 6.3: Dietary requirement of the family and the balance (Nutrient wise)

Sl Ag Se Type Physiologi Nutrient requirement according to RDA

. e x of cal Status
Wor
k

Calories Protein Iron Vita Thiamine Riboflavin Vit C

(Kcal) (gm) (mg) A (mg) (mg) (mg)
(µg)

Total requirement

Total Consumed

Balance %

Result of Assessment of salt iodine estimation.

Schedule for anthropometric and clinical measurement of Under 5 children

 Anthropometric
Ht in cm
Weight (in g)

Age/Wt
Age/HT
Height/length
Mid-arm
circumference (in
cm)

Clinical

Parameters
General
Appearance

Hair
Face

Eyes

Lips
Tongue
Teeth

Gums
Glands

Skin
Nails
Edema
Rachitic Change

Hepatomegaly
Calf Tenderness

Ankle and knee

jerks
Physiological
changes

i. Cooking and food handling practices

 Vegetables washed thoroughly and not merely rinsed in water
 Storage of vegetables/ perishables and not perishables
 Cooked food consumption/ storage / reheating etc.
 Cleaning of kitchen utensils and inspection of few of the commonly
used vessels for cooking and serving, to ascertain the cleanliness
of the vessels.
 Inspect the utensils used for infant feeding (including feeding bottle
for cleanliness/smell/and grease.

CULTURAL PRACTICES OF THE FAMILY

Note down the specific cultural practices prevalent in the family such as:
7. Withholding food items during antenatal period
8. Delivery at home itself
9. Pre lacteal feeds
10. Withholding colostrum
11. Application on the umbilical cord
12. Branding
13. Withholding food items during postnatal period
14. Method of preparation of certain foods
15. What do they do when a child has chicken pox
 Schedule for Under-5 Health Checkup
1 General information
Name- Age (in completed months) Sex
2.Chief Complaints:

3.History of Present Illness:

4.Birth History:
Date of birth: Birth weight: Term/Post Term/ pre term
Place of delivery: Birth attendant: Type of delivery:
5.Feeding practices
Prelacteal feed given- yes / No If yes specify-
Breast feeding started when after birth-
If delayed reason for same
Exclusive breast feeding given-
For how many months –
Complementary feeding started at what age-

Type of food given- Frequency –

Breast feeding continued till what age-
If artificial milk given- yes / No
If yes By bottle / katori
For children > 1 year of age-
Whether eating from family pot or not
Frequency and type of food given-
Whether food made energy dense or not

5.History of Significant past illness (including congenital diseases):

6.Milestone of development (upto 2 years)

2-4 months eye conact,social smile,respond to sound
4-6 months-holds head straight, tries to grasp subject, ulnar grasp, sucks on hand
6-9 months – rollover, grasp small objects using his whole hand, utter consonants
9-12 months- sit without support, transfer objects from one hand to other,
babbling, enjoys playing hide and seek
12-15 months –picks up subject using thumb and index finger . cries when picked
up by strangers
15-18 months – scribble spontaneously, imitates household task, points to body
parts
7.Dentition-
8.Feeding History (24 hour recall):
Type:
Amount and method:
Frequency:

9.
Anthropometric
Ht in cm
Weight (in g)

Age/Wt
Age/HT
Height/length
Mid-arm circumference (in cm)
Head circumference in cm

Chest circumference in cm

Clinical
Parameters
General Appearance
Hair
Face
Eyes

Lips
Tongue
Teeth
Gums
Glands
Skin
Nails
Edema
Rachitic Change
Hepatomegaly
Calf Tenderness
Ankle and knee jerks
Physiological changes

Investigations (if any):

Growth chart (attached Separately):

7.4.Immunization Status of Child

Name of Vaccine Age at Vaccination Place of Remarks

vaccination
BCG
OPV
HEP B
Pentavalent 1,IPV,
Rota
Pentavalent 2,IPV
Pentavalent 3,IPV
Measles (1st Dose
MMR
Vit A

Any other
Any Adverse reaction/s following immunisation experienced:

Reasons for non-immunization/partial immunization:

Provisional diagnosis (if any):

Treatment and management

7.5.1 Knowledge and Practice towards Infant feeding (for the youngest child)
Knowledge to be elicited from all mothers/care giver of underfive babies and
practice to be elicited from mothers/caregivers of infants only

Topic Current Practice Reason for

Knowledge deviation

Type of first food

offered after birth
Colostrum feeding
What is this
Whether
Given/discarded

Brest Feeding
Initiation
After Normal
Delivery
After Cesarian
Section

EBF
What is EBF
Duration

Breast feeding
Frequency
(for last 24 hours
*)

Demand feeding

Breast feeding
(duration in
months)

Complementary
feeding
Initiation(months)
Type of food to be
offered
consistency

If Liquid
supplementation
to be given
mention tool of
feeding :Bottle/
catori
spoon/others

Feeding during
illnesses

*(mention night feed)

7.5.2 Knowledge of mother about Immunization (Knowledge
to be elicited from all mothers/care givers of underfive
babies)
Topic Knowledge
What vaccines should be given to the children
after birth(name of the vaccines)

What diseases are prevented by the

mentioned vaccines

Pulse polio

Vitamin A Prophylaxis (When,why,how)

Next vaccination date of the child/children

Where vaccination facility is available

Lesson 8: Family planning and antenatal,natal and postnatal

care
8.1 Knowledge and practice about Family Planning:(data to be collected from all currently
married women in the family)
Topic Knowledge Practice Reason if deviation
Legal age of marriage

Ideal age of
pregnancy

Interval between
Pregnancies

Reproductive
Intention (how many
children
Gender Preference
Contraceptive
Methods (methods
available, source,
Usefulness)
(Both current and
past)

* In knowledge write opinion of girl child’s future

Health Checkup of Individual Family members

1.Patient Particulars Date of examination
:
Name: Age: Sex:

Occupation:

2. Medical History
Presenting Complaints, with duration:

History of present illness:

History of relevant past illness with Medical History:

Family history:

Personal history:

3 Clinical examinations:
General Survey:
Height: Weight: BMI:
Waist Circumference: Hip Circumference: Waist-Hip Ratio:
Pallor: Cyanosis: Icterus: Clubbing: Edema:
Pulse: BP: Respiration:
Others:
Systemic Examination:
Examination of Chest:
Inspection:
Palpation:
Percussion:
Auscultation: Heart Sound: Lung Sounds:
Examination of Abdomen:
Inspection: Palpation:
Percussion: Auscultation:
Nervous system:
Skeletal system:
Any other findings:
.4 Significant Investigation findings:

Health Checkup of Individual Family members

1.Patient Particulars Date of examination
:
Name: Age: Sex:

Occupation:

2. Medical History
Presenting Complaints, with duration:

History of present illness:

History of relevant past illness with Medical History:

Family history:

Personal history:

3 Clinical examinations:
General Survey:
Height: Weight: BMI:
Waist Circumference: Hip Circumference: Waist-Hip Ratio:
Pallor: Cyanosis: Icterus: Clubbing: Edema:
Pulse: BP: Respiration:
Others:
Systemic Examination:
Examination of Chest:
Inspection:
Palpation:
Percussion:
Auscultation: Heart Sound: Lung Sounds:
Examination of Abdomen:
Inspection: Palpation:
Percussion: Auscultation:
Nervous system:
Skeletal system:
Any other findings:
.4 Significant Investigation findings:
 Examination of the Pregnant woman

1. Particulars of the mother( data to be elicited from all mothers of underfives)

Name: Age (in years): Age of marriage (in years):

Parity: Gravida
Occpation
Education
SES-
Education of husband
Occupation of husband
Joint family/ Nuclear family
2. Menstrual History:
Age at Menarche: Menstruation: Volume:
Duration: Periodicity:

3 EDD LMP

4. History of previous pregnancy (including abortion):

Order of Age at ANC Sex Type of Place Conducted Complications, Outcome
Pregnancy Pregnancy Yes/No of delivery of by If any Abortion/Live birth/Still
How child delivery born/Term/Prevterm
many
tmes

5.Other Significant Histories:

Relevant medical illness:

Any Abdominal operation:

Relevant family history:

6. Clinical records of antenatal care of present pregnancy

Item Visit 1 Date: Visit 2 Date: Visit 3 Date: Visit 4 Date

History Gestation period

(weeks
Other Significant
Complaint

General Height (cm)

Survey
Weight (kg)

MUAC
BP (mm Hg)

Pallor
Edema

Obstetric Fundal Height

examination (weeks)

Lie
Presentation
Fetal Heart Sound

Breast Examination

Other Significant
Findings

Investigations Hb%
Urine Examination
(sugar, protein

Other test findings

(VDRL, Blood
group, USG, etc)
Advice IFA
Calcium

Albendazole

Supplied
/prescribed
consumed

TT Given 1st
dose
2nd dose
3rd dose

Other Advices

Registration date
Place of registration
Janani Surakshya Yojana
Is she availing Pradhan Mantri Matrutya Scheme ?
If yes where

Does she has delivery plan ?

If yes in which institution
Does she know about danger signs?
If yes ask her
Does she know when to start breast feeding ?
Any plan for contraception?
Birth registration

Summary of the case :-

Problems identified

Suggestion s provided

Examination of the Lactating woman (To be taken within one year of child birth)

1. Particulars of the mother( data to be elicited from all mothers of underfives)

Name: Age (in years): Age of marriage (in years):

Parity
Occpation
Education
SES-
Education of husband
Occupation of husband
Joint family/ Nuclear family
2. Menstrual History:
Age at Menarche: Menstruation: Volume:
Duration: Periodicity:

3 LMP Date of last child birth-

4. History of previous pregnancy (including abortion):

Order of Age at ANC Sex Type of Place Conducted Complications, Outcome

Pregnancy Pregnancy Yes/No of delivery of by If any Abortion/Live birth/Still
How child delivery born/Term/Prevterm
many
tmes

5.Other Significant Histories if any-

1. Relevant medical illness:

2. Any Abdominal operation:

3. Relevant family history:

6.
1. After how many days discharged from health facility after delivery( if institutional
delivery )

2.Visits to health care system after how many days of delivery Yes/no
If yes to where
or /home visits by HW / ASHA/ AWW

3.Examinations during post natal checkup

Weight of baby- Umbilical cord Bathing of baby

For mother
Lochia
Scar if any
BP
Breasts
temperature

4.IFA consumption
in antenatal period -No of IFA consumed
No of Calcium tablets
Al;bendazole tablets
Post partum period –
IFA
Calcium

Any restriction in diet

Diet
Family planning
Immunization of baby (Started when)
Advices from healthcare staffs on family planning,
child feeding, child care,breastfeeding etc

Birth Registration
JSSK Complications (if any) Others (specify)

General examination-
BP Pulse Temperature
Relevant systemic finding
lochia,
Fundal height,
breast.
stitch,
bowels)
For Baby
Weight
. Cord,
eyes,
stool,
bath)
Jaundice-
Any complaintAdvice

Breast feeding started when afterdelivery

Any prelacteal feed given
If yes for how many days what is given
How it is given
Frequency of breast feeding –day time night time
Exclusive breast feeding given for how many months-
Artificial feeding given-yes/ No
Frequency—Amount
Whether bottle fed/ Katori & spoon
Type of artificial milk used-

Breast feedibng
a. Position
b. Attchamnet
c. Sucklinf
 d. Frequency

Complimentary feeding
Age at which started
Frequency
Type of food

For children > 1 year of age

Whether feeding rom family pot
Frequency/Types of food given
Whether food made energy dense

Immunization status- Age appropriate received all vaccines yes/ No

Any illness of the child in last 6 months for which trewatment given/admitted

Summary

Problems identified

Suggestions

For Mother

Baby
DIETARY PRACTICES
j. Type of diet – Vegetarian/Non vegetarian
k. Staple diet – Rice/Ragi/Wheat/Maize
l. Procurement of raw food: Cereals, vegetables, fruits and groceries
m. Calculate the consumption units for the family
n. Method used for dietary survey: Stock Inventory method/ 24 hr dietary
recall
o. Dietary co efficient is defined as the energy requirement of an adult male
sedentary worker i.e. 1 D C = 1 adult consumption unit = 2400 kcal
(ICMR Recommendation)

Energy
Category Type of work Dietary Co efficient
Requirement
Adult Male sedentary worker 1.0 2400
moderate worker 1.2 2800
heavy worker 1.6 3900
sedentary worker 0.8 1900
Adult female moderate worker 0.9 2200
heavy worker 1.2 2800
Adolescents 12 – 21 yrs 1.0 2400
10 – 11 yrs 0.8 1900
8 – 9 yrs 0.7 1700
6 – 7 yrs 0.6 1440
Children
4 – 5 yrs 0.5 1200
1 – 3 yrs 0.4 1000
< 1 yr 0.3
p. For one consumption unit the following is the balanced diet prescribed

Cereals 460 g
Pulses 40 g
Green Leafy vegetables 40 g
Other vegetables 60 g
Roots and tubers 50 g
Milk 150 g
Fat/Oil/Ghee 40 g
Sugar/ Jaggery 30 g

 Estimate the amount of food items used by the family per day.

 Estimate the amount they should actually be using according to the

RDA

 Then compare the above two and calculate the deficiency or excess;
and comment
  Also calculate the energy and protein deficiency or excess for the
entire family
i.e. 2400 k cal per consumption unit (+ 300 kcal for pregnancy; +
550 kcal for the first 6 months of lactation; + 400 kcal for 6 – 12
months of lactation)
AND protein of 1 g/kg of body weight

q. Cooking and food handling practices

 Vegetables washed thoroughly and not merely rinsed in water
 Storage of vegetables/ perishables and not perishables
 Cooked food consumption/ storage / reheating etc.
 Cleaning of kitchen utensils and inspection of few of the commonly
used vessels for cooking and serving, to ascertain the cleanliness
of the vessels.
 Inspect the utensils used for infant feeding (including feeding bottle
for cleanliness/smell/and grease.

CULTURAL PRACTICES OF THE FAMILY

Note down the specific cultural practices prevalent in the family such as:
16. Withholding food items during antenatal period
17. Delivery at home itself
18. Pre lacteal feeds
19. Withholding colostrum
20. Application on the umbilical cord
21. Branding
22. Withholding food items during postnatal period
23. Method of preparation of certain foods
24. What do they do when a child has chicken pox

KAP REGARDING HEALTH AND DISEASE

8 age at marriage-
9 age at first child birth-
10 family size-
11 women’s education-
12 and employment-
13 food taboos-
14 knowledge regarding diseases- Rational/ Deistic/ Demonic/ Supernatural causation-
and cure
15 Sources of health related information for the family is from: Radio/ TV/ Newspaper/
Health worker/ AWW/ any other
16 What do you think the age of marriage should be?
17 What do you think the age at first child birth should be?
18 Do these have an impact on health?
19 Outlook on causes of disease:
20 Outlook on prevention and cure of diseases: Rational / Religious/ Fatalistic/ Stoic

SUMMARY:

HEALTH STATUS OF THE MEMBERS OF THE FAMILY (available for examination)

Sl. No. Name History Anthropometry Other examination
1
2
3

INDEX CASE: Neonate/ Infant/ Under five/ Adolescent/ Antenatal woman/

Postnatal woman/ Geriatric/ any specific disease
Relevant history:

Examination:
a. General-

b. Systemic

c.

COMPLETE DIAGNOSIS/COMPREHENSIVE PROBLEM LIST (in the order of priority)

This is the family of Mr. residing in..................... (an urban slum)
belonging to ...... socioeconomic status. The health problems, health demands
and health needs of this family are.............................

The vulnerable individuals identified in this family are....

(Why are they vulnerable?).

Any medical diagnosis in a particular individual has to be mentioned in the end.
RECOMMENDATIONS
1. To the family on the whole

2. To specific individuals/ index case

3. To the community at large

Assessment of Adolescent Girl (To be conducted by the lady student)

Name : ……………….......................................................................................................................................

Age : Sex : Religion :

Education : ……………………………………………………………………………………………………………………………………………….

Occupation if any : ……………………………………………………………………………………………………………………………………

Maritial Status : ………………………………………………………………………………………………………………………………………..

Any Complain : ………………………………………………………………………………………………………………………………………….

History of past illness : ………………………………………………………………………………………………………………………………

 Relationship with siblings and Parents : ………………………..

Staying with --- parents/Alone/Friends

Is she feeling neglected…. Yes/no

Sharing of enotions and feelings with whom

Faith on dicine ……

Any addiction : Yes/No

If yes, type: ……………………………………………………………………………………………………………………………………………….

Age of initiation of addiction : …………………………………………………………………………………………………………………..

Reason for initiation of addiction : ……………………………………………………………………………………………………………

Knowledge of parents regarding addiction of daughter : ………………………………………………………………………….

Immunization history : ………………………………………………………………………………………………………………………………

Menstrual History :

 ……………………………………………………………………………………………………………………………………………………
Age at Menarche …………………………………………………………………………………………………………………………

 ……………………………………………………………………………………………………………………………………………………..
Cycles …………………………………………………………………………………………………………………………………………

 …………………………………………………………………………………………………………………………………………………….
Duration ………………………………………………………………………………………………………………………………………

 …………………………………………………………………………………………………………………………………………………….
Frequency …………………………………………………………………………………………………………………………………….

 ……………………………………………………………………………………………………………………………………………………
Any complain during menstruation ……………………………………………………………………………………………..

Menstrual Hygiene

 ……………………………………………………………………………………………………………………………………………………
Regular bath during menstruation : Yes/No
Use of diaper – type – Sanity napkin/old clothes/ washed & reused/ not reused

 ……………………………………………………………………………………………………………………………………………………
Any social restriction during menstruation
(If yes Mention)
 …………………………………………………………………………………………………………………………………………………..
Knowledge about contraception : Yes/No
If yes, ,mention the name : …………………………………………………………………………………………………………

 …………………………………………………………………………………………………………………………………………………..
Source of information about contraceptive ………………………………………………………………………………..

 …………………………………………………………………………………………………………………………………………………….
Knowledge of contraceptive which will also protect form RTI, STD, HIV – Yes /No :
If yes mention the name : …………………………………………………………………………………………………………….

 …………………………………………………………………………………………………………………………………………………….
Knowledge about RTI/STD : Yes/No

 …………………………………………………………………………………………………………………………………………………….
Knowledge regarding availability of safe place of abortion for those who have become pregnant
unintentionally : Yes/No ………………………………………………………………………………………………………………
If Yes – mention …………………………………………………………………………………………………………………………..

 ……………………………………………………………………………………………………………………………………………………
Any myth regarding menstruation & Child birth ………………………………………………………………………….

 ……………………………………………………………………………………………………………………………………………………
Whether practicing Yoga & Exercise : ………………………………………………………………………………………….

 ……………………………………………………………………………………………………………………………………………………
Any training received in the school/community about coping with stressful situation ……………….

 ……………………………………………………………………………………………………………………………………………………
For any health related problem whom they consult …………………………………………………………………..

 ……………………………………………………………………………………………………………………………………………………
Awareness about development of secondary sexual character : Yes/No
If Yes – describe ………………………………………………………………………………………………………………………….

 …………………………………………………………………………………………………………………………………………………...
Knowledge regarding self protection : Yes/No :
(Specifically to protect oneself form sexual abuse)

 …………………………………………………………………………………………………………………………………………………….
Knowledge about legal age of marriage for both boys and girls …………………………………………………..
  ………………………………………………………………………………………………………………………………………………......
Do you have a role model whom you want to follow

 …………………………………………………………………………………………………………………………………………………….
Any pre marital sexual contact history : Yes/No

Food habit : Vegetarian/ Non Vegetarian : Presence of any food fad ………………………………………………………….

Knowledge about Balanced diet : ………………………………………………………………………………………………………………..

Knowledge about role of food on growth and development : ……………………………………………………………………..

General Examination :

Height ……………… Weight ………………… Temperature ……………. Pallor ………………….. Lcterus …………………

Body build ……………… BMI ………………… Carries tooth ………………….. Gingivitis ……………… Goiter ……………….

Pulse …………………. BP ………………. Lymphadenopathy …………………. Condition of skin ………………………………

Condition of hair …………………… Presence of acne ……………………. Bladder and Bowel habit …………………….

General Cleanliness …………………………………………………………………………………………………………………………………….

Any deformity present ………………………………………………………………………………………………………………………………..

Systematic Examination

Problem identified and suggestions given :

Assessment of Adolescent Boy

Name : ……………….......................................................................................................................................

Age : ………………………………………………………………………………………………………………………………………………….

Sex : …………………………………………………………………………………………………………………………………………………

Religion : …………………………………………………………………………………………………………………………………………………..

Education : ……………………………………………………………………………………………………………………………………………….
Occupation if any : ……………………………………………………………………………………………………………………………………

Maritial Status : ………………………………………………………………………………………………………………………………………..

Any Complain : ………………………………………………………………………………………………………………………………………….

History of past illness : ………………………………………………………………………………………………………………………………

Relationship with siblings and Parents : ………………………..

Staying with --- parents/Alone/Friends

Is she feeling neglected…. Yes/no

Sharing of enotions and feelings with whom

Faith on dicine ……

Any addiction : Yes/No

If yes, type: ……………………………………………………………………………………………………………………………………………….

Age of initiation of addiction : …………………………………………………………………………………………………………………..

Reason for initiation of addiction : ……………………………………………………………………………………………………………

Knowledge of parents regarding addiction of daughter : ………………………………………………………………………….

Immunization history : ………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………....

 …………………………………………………………………………………………………………………………………………………….
Any pre marital sexual contact history : Yes/No

 …………………………………………………………………………………………………………………………………………………….
Knowledge about contraception : Yes/No
If yes, ,mention the name : …………………………………………………………………………………………………………

 …………………………………………………………………………………………………………………………………………………..
Source of information about contraceptive ………………………………………………………………………………..

 …………………………………………………………………………………………………………………………………………………….
Knowledge of contraceptive which will also protect form RTI, STD, HIV – Yes /No :
If yes mention the name : …………………………………………………………………………………………………………….

 …………………………………………………………………………………………………………………………………………………….
Knowledge about RTI/STD : Yes/No
  ……………………………………………………………………………………………………………………………………………………
Any myth regarding masturbation and premature ejaculation ………………………………………………….

 ……………………………………………………………………………………………………………………………………………………
Knowledge about legal age of marriage for both boys and girls ………………………………………………….

 …………………………………………………………………………………………………………………………………………………….

 …………………………………………………………………………………………………………………………………………………….
Whether practicing Yoga & Exercise : …………………………………………………………………………………………..

 ……………………………………………………………………………………………………………………………………………………
Any training received in the school/community about coping with stressful situation ……………….

 ……………………………………………………………………………………………………………………………………………………
For any health related problem whom they consult …………………………………………………………………..

 ……………………………………………………………………………………………………………………………………………………
Awareness about development of secondary sexual character : Yes/No
If Yes – describe ………………………………………………………………………………………………………………………….

 …………………………………………………………………………………………………………………………………………………...
Knowledge regarding self protection : Yes/No :
(Specifically to protect oneself form sexual abuse)

 ………………………………………………………………………………………………………………………………………………......
Do you have a role model whom you want to follow

Food habit : Vegetarian/ Non Vegetarian : Presence of any food fad ………………………………………………………….

Knowledge about Balanced diet : ………………………………………………………………………………………………………………..

 …………………………………………………………………………………………………………………………………………………….
Knowledge about role of food on growth and development : ……………………………………………………..

General Examination :

Height ……………… Weight ………………… Temperature ……………. Pallor ……………………………………………………

Body build ……………… BMI ………………… Carriers tooth ………………….. Gingivitis ……………… Goiter …………….

Pulse …………………. BP ………………. General Cleanliness …………………. Condition of skin ……………………………

Condition of hair …………………… Presence of acne ……………………. Any deformity present ………………………..

Bladder and Bowel habit …………………………………………………………………………………………………………………………..

Lymphadenopathy ……………………………………………………………………………………………………………………………………..

Systematic Examination

Problem identified and suggestions given :

Assessment of Geriatric age group -

 Animal Bite case study
Name of the patient
Age sex
Address weight
Education
Occupation
Income –
History of present illness
No of bite
Site of bite
Biting animal
Provoked / Not provoked
Bleeding
Class of bite
Firsrt aid received

If yes what and where

Immunoglobulin prescribed
Mention dose - site route of administration
Mention schedule of vaccine
Course completed
Side effects observed

Clinico social case study

Name of the patient Date of examination

c/o
address
Age sex
Occupation
Income
Chief complaint
Hist of present illness
Hist of [ast illness
Family hist
Social hist
General examination
Body built Height wiught BP Pulse Pallor Icterus Oedema Lymphnode enlarge ment
Any hypopigmented patches any other skin lesion
Systemic examination

Members of the family of the index case

Name Relation Age in Sex Occupation Education Hist of Immunization

to the ye ar any
patient illness

Environment Type of house rented /own

No of rooms
No of persons per room
Over crowding
Ventilation
Cross ventilaton Lighting
Separate kitchen
Toilet

Water supply drinking for other use

Surrounding of the house

Clean
Food habbit – any restriction

SES
Effect of family towards illness
Effect of patiets illness on the family – Economy
Social

Intrafamilial relationship
Relation with neighbours
Summary of the case
Problems identified
Mediacl
Social
Management –

Which level of prevention has not been effective in this case

Management at various level

Healh Specific Early Rehabilitation Disability
promotion protection diagnosis & limitation
Trewatment

Individual

Fami ly

Community Level

Visit to NRC

Examination of the Under Five

Examinatio of the Pregnanat woman
Examinatiuon of the lactating women
Examination of the Adoloscent girl
Examination of the Adoloscent Boy
Examination of the Geriatric age group Male
& Female

Clinico Sociual case study

Visit to NRC
Visit to Labour Room
Visit to ARC
Visit to Immunization Clinic-
Visit to UHND session-
Visit to DOTS centre
Visit to Water Treatment plant

ALTERNATIVE MEDICINES
The Indian systems of medicine and homeopathy consist of Ayurveda, Sidha, Unani and
homeopathy and therapies such as yoga and Naturopathy. Some of these systems are
indigenous and others such as homeopathy have over the years become a part of Indian
tradition. Visit one of the above centres and write a brief note.
Signature of Teacher Signature of Student

VISIT TO ANGANWADI CENTRE

3.1 General Information
Name of the Village / Urban locality
Name of the Block / District & State
Code No.
Population covered by Anganwadi Centre
Year of starting the Anganwadi Centre
Number of households in the centre
Caste wise distribution of these households.
Sl. No. Caste Number of house holds in the population
1.
2.
3.
4.
Distribution of beneficiary groups in the population covered by the Anganwadi :
Sl. No. Type of beneficiary Number in the population
1. Children below 3 years
2. Children between 3-6 years
3. Pregnant women
4. Lactating women
5. Adolescent girls (10-19 years)
3.2 Physical Infrastructure
Comment on the building of the Anganwadi centre
Is it accessible to all mothers and children? Yes/No
Is it properly cleaned? Yes/No
Is there any electricity connection? Yes/No
Water supply source in the anganwadi : Handpump/Piped water/well/other
Toilet facilities present? Yes/No
Is there enough space for storage of food items that are distributed to the children? Yes/No
Is there sitting arrangements for children and mothers appropriate? Yes/No
Type o fuel used for cooking : Gas/ Kerosene/wood
Who cooks the food for children usually?

3.3 Supplementary Nutrition Services at the Anganwadi Centre

Distribution of beneficiaries of supplementary Nutrition
Sl. No. Type of beneficiary Number enrolled Number present
In register on the day of visit
Children below 3 years
Children between 3-6 years
Pregnant women
Lactating women
Food items usually given for supplementary Nutrition.
Sl. No. Type of beneficiary Food item usually given
Children below 3 years
Children between 3-6 years
Pregnant women
Lactating women
List of difficulties faced by Anganwadi worker in relation to food item.
Sl. No. Type of the activity Diffuculty faced
Procurement
Transportation
Preparation
Storage
Distribution
Record keeping
Distribution of IFA Tablets to the Adolescent girls
IFA tablet present in AWC Yes/No
Tablets distributed to the target group Yes/No
Reason for the same
3.4 Non-formal pre-school Education
Number of beneficiaries of Pre-school education present on the day of visit.
List the material available at Anganwadi Centre for non-formal pre-school education at the
Anganwadi Centre.
Ask the Anganwadi worker and list the difficulties faced by her in implementing non-formal Pre-
school education in the Anganwadi Centre.
3.5 Growth Monitoring
From the growth monitoring record, find the following information.

Sl. No . Type of Beneficiary Number having Number having Number having

Normal rising stationary declining growth
growth growth
Children below 3 years
Children between3-6 years

Ask the Anganwadi worker what actions are taken by her for a child who is not gaining weight,
a child who is in grade III/IV malnutrion.

Ask the Anganwadi workers to tell the difficulties faced by her in monitoring growth.

3.6. Treatment of Common Ailments

From the records available at the anganwadi centre find out the following information
regarding the treatment of common ailments by the anganwadi worker.
Sl. No. Type of Common Ailments Number treated in last one month
ARI
Long drawn Cough/Cold/TB
Fever
Diarrhoea
Skin infection
Anemia
 Worm infestation
Others
Observe the treatment kit available and check for the drug position.
Ask the anganwadi worker to tell the difficulties faced by her in treating the common ailments.

3.7. Nutrition and Health Education Services

Comment on the health and nutrition education materials and messages available at the
Anganwadi Centre.

Ask the Anganwadi worker to tell the difficulties faced by her in providing nutrition and health
education services.

3.8. Activities in Field

Observe the weighing scale and check for its accuracy.
Ask the AW to weigh a child who is infant and a child of 1-6 years of age and ask her to record
their weights on the growth monitoring cards. Comments on her skills to do so.

Interview one mother of children in 3-6 years of age who had been attending Anganwadi centre
regularly and seek their opinion regarding the impact of non-formal pre-school education on
the development of children.

Visit one beneficiary of supplementary nutrition and inquire whether the feeds are available
regularly?
Seek suggestions for improvement of these services at Anganwadi.

Signature of Teacher Signature of Student

Visit to Health & Wellness Center
General Information
Name of the village/urban locality
Name of Block/District & State
Population covered by Sub-centre
Details of the households in each village covered under the sub-centre
Sl. No. Name of the Village Number of households Population
1
2
3
4
5
Physical infrastructure at Sub-Centre
Total Number of rooms
Functions of each room
Verandah/waiting place available : Yes/No.
Is there waiting place protected form sun/rain water : Yes/No
Room Flooring/Plastering done : Yes/No
Electrical Supply (Number of hour supplied in a day)
Type of water supply : Tap/Well/Pump/Any other
Room for Clinic : Separate/ attached
If there is water outlet in clinic room : Yes/No
Whether washing basin provided and functioning : Yes/No
Toilet available : Yes/No
Is the location of sub-centre accessible to all : Yes/No
If no, list reason :
Availability of residential facilities for health worker at sub-centre : Yes/No
Equipment availability at Sub-centre
Please comment on the availability and usability considering the number of beneficiaries in the
areas covered by Sub-centre.
Sl. No. Equipment AvailabilityTick mark (P) Usable
if available (Yes/No) (Yes/No)
1. Examination Table/Stool
2. Mattress with Macintosh
3. Bed sheets
4 Writing tables with chair
5 Vaccine carrier
6 Autoclave
7 Sterilizer
8 Stove
9 Weighing Machine (Adult)
10 Baby Weighing scale
11 BP Apparatus
12 Haemoglobin testing kit
13 Urine test (Reagents & Test Tubes)
14 Sugar Test (Reagents & Test Tubes)
15 Spirit Lamp
16 ORS Packets
17 CS SM Kit
18. Drug Kit
19 Delivery Kit
20 Enema Can & Tube
21 New Blades
22 Scissors
23 Gauze
24 Gloves
25 Soap
26 Kidney Tray
27 Catheter
Antenatal Services
Please refer to records of mothers who delivered in the last year and collect following
information:
Sl. No. Type of Event Number recorded
1. Pregnant women registered with Sub-centre
2. Received three antenatal checkups
3 Received at least 100 tab of folifer
4 Two doses of inj. Tetanus toxoid or one booster of TT
5 Hemoglobin tested
6 Urine tested
7 Blood pressure checked up
8 Weight was recorded
Number of high risk pregnancies detected and referred.
Intra-Natal and Post Natal Service Provided at Sub-Centre
Please refer to the records of women who were delivered last year in the sub-centre area
and collect the following information.
Total delivery registered
Number of institutional deliveries
Number of women delivered by
Trained Dai
Untrained Dais
MPW(F)
Doctors
Pregnancy outcome
Under 2500 gms
2500 gms and above
Weight not known
Early child death within 28 days of birth
Still birth
Abortions
High risk cases referred
Before delivery
During delivery
After delivery
Number of Maternal Deaths
Ask about the Post-natal services provided at the sub-centre and comment on them.
Child Health Services at the Sub-Centre
Please refer to the immunization records of children 12-23 months in the sub-centre and
collect the following information.
Number of children in the age 12-23 months of age:
Number received the following vaccines:
Sl. No. Type of vaccine Number vaccinated
BCG
DPT-1
DPT-2
DPT-3
OPV-1
OPV-2
OPV-3
Measles
Number of children who has received BCG+OPV3+DPT3+Measles.
Family Planning Services Provided at Sub-Centre
Please refer to the FP Records from eligible couple register in the sub-centre and collect the
following information.
Eligible couples in the area:
Number of couples adopting the following family planning methods:
Terminal methods
IUD
Oral Pills
Condoms (Nirodh)
Number of MTP cases referred in a year.
Treatment of Minor Ailments at Sub-Centre
Please refer to treatment register at sub-centre for the last one year and list the number of
cases seen at sub-centre.
Sl. No. Type of common ailments Number treated in last 1 month
1. ARI
2. Long drawn Cough/Cold/TB
3. Malaria
4. Fever
5. Diarrhoea
6. Skin infection
7. Anemia
8. Worm infestation
9. Eye infection
10. Minor injuries
11. Others
Specify if there is any occurrence of vaccine preventable disea ses.
Activities in the field
Ask the health worker to tell the difficulties faced by her for the following components.
Antenatal services
Intranatal services
Immunization services
Family Planning Services
Treatment of Minor Ailments.
Interaction with ASHA
Meet the Accredited Social Health Activist (ASHA) and collect the following information for
the last one year.
one year:
Number of village health nutrition days held
Number of children who need care for malnutrition
Number of children with special needs, particularly girl children
Number of children with disabilities
Number of persons with severe anemia
Number of pregnant women identified from BPL households
Number of such women registered at the sub-centre/PHC
Number of ANC visits for each of these women
Number of postnatal visits made to the mothers
Number of lactating women counseled on breast feeding.
Number of patients requiring anti-TB drugs
Number of patients provided DOTS treatment
Number of household toilets constructed.
Calculate the Following
Calculate the following with the help of the data recorded by you under Section 1.4.
Percent of women registered at Sub-Centre
Percent of women received three antenatal checkups at Sub-Centre
Percent of women received 100 tablets of iron folic acid at Sub-Centre
Percent of women received inj. TT at Sub-Centre
Percent of women haemoglobin tested at Sub-Centre
Percent of women urine tested at Sub-Centre
Percent of women BP measured at Sub-Centre
Percent of women weight recorded at Sub-Centre
Calculate the following with the help of the data recorded by you under section 1.5.
Percent of deliveries by the Trained dais
Percent of deliveries by untrained dais
Percent of deliveries by health worker
Percent of deliveries by doctors
Calculate the % of children in the age group 12-23 months who have received the following
vaccines with the help of the data recorded by you under Section 1.6.
BCG
OPV-3
DPT-3
Measles
BCG+OPV-3+DPT-3+Measles
Calculate the % of eligible couples protected by various methods with the help of the data
recorded by you under section 1.7.
Percent of eligible couples protected with Temporary methods
Percent of eligible couples protected with Permanent methods
Conclusions
What are your major conclusions about the performance of sub-centre?
Suggestions
What are your suggestions for improving these services at the sub-centre?
 VISIT TO COMMUNITY HEALTH CENTRE
General Information
Name of the Block/District & State
Population covered by Community Health center
Details of the PHCs and sub-centres under the CHC
Sl. No. Name of the PHCs Number of Sub-centers Population
1
2
3
4
Physical infrastructure at CHC
Total Number of rooms (OPD, Indoor, Lab, Store, Injection room, emergency, store rooms for
Drugs etc.)
Total number of rooms
Functions of each room
Verandah/waiting place
Is the waiting place protected from sun/rain water: Yes/No
Room Flooring/Plastering done : Yes/No
Electrical Supply (Number of hour supplied in a day)
Type of water supply: Tap/Well/Pump/Any other ‘
Room for Clinic: Separate / attached
If there is water outlet in clinic room: Yes/No
Whether washing basin provided and functioning: Yes/No
Toilet available: Yes/No
How do you maintain cleanliness of the primary Health Centre?
Number and types of residential quarters available
Electricity available (Number of Hours)
Water supply to the Quarters
If the medical officer-in-charge is not staying in the CHC then the reasons
Equipment availability at Primary Health Centre and Manpower Available for various
Categories
Please comment on the availability and usability of manpower and equipment considering the
number of beneficiaries in the area covered by CHC.
Antenatal services
Please refer to records of mothers who delivered in the last year and collect following
information.
Sl. No. Type of event Numbers recorded
Pregnant women expected in the CHC area
Pregnant women registered with CHC
Received three antenatal check ups
Received at least 100 tab of folifer
Two doses of inj. Tetanus toxoid or one booster of TT
Hemoglobin tested
Urine tested
Blood pressure checked up
Weight was recorded

Intra-natal and post-natal service

Please refer to the records of women who delivered last year in the CHC area and collect the
following information.
Total delivery registered
Number of women delivered by
Trained Dai
LHV
Staff nurse
Doctors
Pregnancy outcome
Under 2500 gms
2500 gms and above
Weight not known
Early child death within 28 days of birth
Still birth
Abortions
High risk cases referred
Before delivery
During delivery
After delivery
Child Health Services at CHC
Please refer to the immunization records/annual report at the CHC and collect the following
information.
Number of children below the age of 12 months
Target of CHC and the number received the following vaccines
Sl. No. Type of vaccine Number vaccinated Target of CHC(% coverage)
BCG
OPV
IPV
Pentavalent
Hep B
Measles
Vit A
Family Planning services provided at CHC
Please refer to the FP records/reports at the PHC and collect the following information Eligible
couples in the area:
Target of the PHC and the number of couples adopting the following family planning methods:
Sl. No. FP Method Total Number Number Accepted Target of PHC
Accepted in last one year (% coverage)
1. Vasectomy
2. Tubectomy
3. IUD
4. Oral Pills
5. Condoms (Nirodh)
Number of MTP cases referred in a year:
Treatment of Minor Ailments at CHC
Please refer to treatment register at PHC for the last one month and list the number of cases
seen at PHC.
Sl. No. Type of common ailments Number treated in last 1 month
1. ARI
2. Long drawn Cough/Cold/TB
3. Malaria
4. Leprosy
5. Fever
6. Diarrhoea
7. Skin infection
8. Anemia
9. Worm infestation
10. Eye infection
11. Others
Indoor Services
Number of beds
Speciality wise distribution of beds
Number of patients admitted in last year
Types of cases admitted
Activities in the Field
Ask about the post natal services provided at Primary Health Centre and Comment on them.
See the cold chain equipment available and comment on the cold chain system.

Visit the ward and comment on the utilization of indoor services.

Ask the Medical officer in charge to tell the difficulties faced by him in delivery of health
services

Calculate the following

Calculate the following with the help of the data recorded by you under section 2.4
Percent of women registered at CHC
Percent of women received three antenatal checkups at CHC
Percent of women received 100 tablets of iron folic acid at CHC
Percent of women received inj. TT at CHC
Percent of women haemoglobin tested at CHC
Percent of women urine tested at CHC
Percent of women BP measured at CHC
Percent of women weight recorded at CHC
Calculate the following with the help of the data recorded by you under section 2.5.
Percent of deliveries by the Trained dais
Percent of deliveries by staff nurses
Percent of deliveries by LHV
Percent of deliveries by doctors
Calculate the % of children in the age group 12-23 months who have received the following
vaccine with the help of the data recorded by you under Section 2.6.
BCG
OPV-3
DPT-3
Measles
Compare the performance of vaccine coverage with the annual target for immunization in the
CHC.
Calculate the % of eligible couples protected by various methods with the help of the data
recorded
by you under section 2.7.
Percent of eligible couples protected with Temporary methods
Percent of eligible couples protected with Permanent methods
Compare the performance of FP activity with the annual target of the CHC.
Conclusions
What are your major conclusions about the performance of CHC?

Suggestions
What are your suggestions for improving these services at the CHC?