Annapoorana Medical College & Hospitals, Salem

Department of Community Medicine

Family Adoption Programme - Log Book

Team Code: Dates of Visit

Family Code: 1.

2.

3.

Name of the student:

Roll No. Registration Name of the student Signature of the

Number student

Name of the Mentor Signature of the Mentor

Signature of Professor and Head

1
Professional Year - I

Objectives:
1. Collect demographic profile of allotted families, take history and conduct
clinical examination of all family members.
2. Organize health check-up and coordinate treatment of adopted family under
overall guidance of mentor.
3. Maintain communication & follow up on remedial measures.
4. Take part in environment protection and sustenance activities.

Target:
1. Learning communication skills and inspire confidence amongst families
2. Understand the dynamics of rural set-up of that region
3. Screening programs and education about ongoing government sponsored
health related programs
4. Learn to analyse the data collected from their families
5. Identify diseases/ ill-health/ malnutrition of allotted families and try to
improve the standards

2
Field Area:
District:
State:
Name of the ASHA/ VHN/ PHN/ SHN/ MPW:
Address of the ASHA/ VHN/ PHN/ SHN/MPW (phone number):

Experience of the ASHA / VHN/ PHN/ SHN/ MPW (IN YEARS):

Number of households in the area:

Total population:
Nearby health facility: Government / Private
Address of the health facility:
Contact person of the health facility:
Name of the mentor:
Mentor status:

Family Details:

S. No. Block Address with Name of Head of Contact

house number the Family Number
1

1. Nearby health facility: Government /Private

2. Distance to nearest health facility ________________________________
3
 3. Preferred system of medicine: 1. Allopathy 2. Ayurveda 3. Yoga 4.Unani 5.
Siddha 6. Homeopathy
4. ICDS Beneficiaries: 1. Antenatal / Postnatal mother 2.Children 0-6 years 3.
Adolescent girls, 4.Women in Reproductive age group
5. Special groups in the family: 1. Antenatal / Postnatal mothers 2. Under five
children 3.Geriatric people 4. Differently abled
6. Vital events in the past 1 year: 1. Births (Y/N) 2. Deaths (Y/N) 3. Marriages
(Y/N) 4.Divorce (Y/N), 5. Migration (Y/N) If yes, Menstion
---------------------------
7. Covered under any health insurance / schemes: 1. State Government 2.
Central Government 3. ESI 4.Private 5. Others (specify):
__________________ 6.None 7. Name of Insurance

LOCATION MAP

Family No:
Address:
Head of the Family:

4
Type of Family: Nuclear/Joint//Three-generation

SI Name A Occu Incom Educa Relation He immuniz

. ge patio e tion ship to alth ation
N / n the Head stat
o. Se of family us
x

Monthly expenditure of the family

Per capita monthly income
Socio-economic status (Updated BG Prasad’s Classification)

Monthly Expenditure:

Sl.No. Items Monthly Expense Percentage to

Monthly Income

5
 1. Rent
2. Food
3. Education
4. Electricity
5. Fuel
6. Clothing
7. Medical
8. Travel
9. Recreation
10. Others
11. Total

Debts / Loans at the time of visit: Annual Savings:

Food habits: Under 5/ ANC/ PNC/ Adolescent/ Geriatric (24 hour dietary recall
method)
Meal Food Item Quantity Calories Protein
Breakfast

Lunch

Snack

Dinner

Total

Food Fads:
Food taboo:

6
Housing Conditions: Own / rented
Type of house : Kutcha/ Pucca / Semi pucca Nature of house : Single / Row
Construction of the house:
Roofing : Terraced / Tiled / Thatched
Walls : Thatti / Mud / Bricks
Flooring : Tiled / Cemented / Mud with cow dung
Number of rooms :
No. of persons / room : Per capita floor space available:
Overcrowding : Present / Absent
Ventilation : Adequate/Inadequate
Cross Ventilation: Present/Absent
Lighting: Adequate/Inadequate

Kitchen
Separate kitchen: Yes/No
Smoke vent provided: Yes / No
Cooking fuel used : Wood/ LPG / Kerosene / Biogas
Platform: Yes/No
Water supply :
Waste water drainage: Open drainage / Closed drainage/ Kitchen garden
Shelves present: Yes / No
Rats / Insects – Present/Absent

Water supply :
Access to public water supply : Present / Absent
Municipal tap: Inside the house / outside the house
Method of storage of water : Over head tanks / drums / Plastic containers

Waste disposal:

Toilet facility: Present / Absent

Open air defecation: Present /Absent
Stagnant water around the house: Yes / No
Disposal of sullage: Sewage:
Segregation of garbage:
Method of garbage disposal:

External environment:

Drainage: Open/closed
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Condition of road:
Street lights: Present/absent
Accident prone zone: Yes/No
Water stagnation: Present/Absent
Mosquito breeding sites: Present/Absent
Stray animals: Present/absent
Nearby factories, quarries, water bodies

Summary of environment conditions and suggestions for improvement

Suggestion to improve sanitation

Motivation on free plantation

8
Summary of environment conditions and suggestions for improvement
(Attach relevant photographs)

9
Immunization of children under 5 years

S. Vaccine First child Second Third child

no child
1 BCG, OPV, Hepatitis – B
( Birth – 2 weeks)
2 Pentavalent – I ; OPV – I;
Rotavirus - I ( 6 weeks)
3 Pentavalent – II ;OPV – II;
Rotavirus - II ( 10 weeks)
4 Pentavalent –III;OPV – III;
Rotavirus - III ( 14 weeks)
5 PCV and IPV – I (6 weeks) &
PCV and IPV – II (14weeks)
6 MR– I dose, Vitamin A (9 –
12 months)
7 DPT – 1st booster ( 16-24
months)
8 MR– II dose, OPV booster (16 –
24 months)
nd
9 DPT – 2 booster (5-6
years)

· Comments on immunization status

· Motivation on immunization given in I, II, III visit

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 HEALTH STATUS OF FAMILY MEMBERS

Name Health Duration On treatment Suggestions for

Problems (Yes/no/ improvement
default)

11
 Reflections - Visit 1

12