(NOTE:- I have changed the names to protect the identity of the family under study.)
Department of Preventive and Social Medicine
All India Institute of Hygiene and Public Health
FAMILY HEALTH CARE PROGRAMME
URBAN HEALTH CENTER, CHETLA
FILLED UP QUESTIONNAIRE
Identification Particulars:
Name of the Head of Family: SAYAN Singh
Type of family: Joint-family
Address: L/L Rama Mahato, 19B Chetla Hat Road.
Religion: Hindu
Caste: Rajput
State of origin: Bihar
Length of residence: Since birth
Mother tongue: Bhojpuri
Particulars of the family members:
Sl no.
|
Names
|
Relation with
HOF
|
Age
(yr)
|
Sex
|
Marital
Status
|
Education
Level
|
Occupation
|
Physical
Activity
|
Physiological
|
Status
|
CU
|
Re-marks
|
1
|
SAYAN Singh
|
HOF
|
30
|
M
|
M
|
Class 10
|
Group D
Worker in
UJALA
|
MW
|
1
| |||
2
|
Biplab Singh
|
Father
of HOF |
60
|
M
|
M
|
Class 5
|
Retired
Car driver,
Agriculture
In Bihar
|
SW
|
1.18
| |||
3
|
Piyali
Singh
|
Wife
of HOF |
26
|
F
|
M
|
Class 8
|
Housewife
|
SW
|
0.82
| |||
4
|
Rakesh
Singh
|
Younger Brother
of HOF |
25
|
M
|
UM
|
Class 12
|
Worker in SUGUNA company
|
MW
|
1.18
| |||
5
|
Sweety
Singh
|
Daughter
of HOF |
5
|
F
|
UM
|
Class 1
|
0.58
| |||||
6
|
Abhinabh
Singh
|
Son
of HOF |
1yr
3months
|
M
|
UM
|
0.46
|
Amenities and recreational facilities:
| |
How does the family get information/news?
|
Newspaper, Radio,Television, interaction with friends and neighbors
|
Possession of:
|
Electricity, Fan, Radio, Television, Tape recorder, Mobile, Motorcycle
|
How do they pass their free time?
|
Watching TV, Catching up with Friends and Community members, Occasional trips Homeland(Bihar) mostly to attend social functions like marriage ceremony etc.
|
Social Problems
| |
Any unemployed member in the family?
|
No
|
Addiction?
|
SAYAN Singh (HOF) occasionally takes Smoke less tobacco (Khaini)
|
Any mother who is unmarried, divorced, or abandoned by husband’s family?
|
No
|
Any handicapped or chronically ill family member?
|
No
|
Any children above 5 years of age not going to school?
|
No
|
Is the mother working anywhere?
|
No, she is a Housewife
|
Child labour (any child less than 14 years working)?
|
No
|
Monthly expenditure of the family
|  | |
Food
|
6,592/-
| |
Fuel
|
405/- (gas cylinder)
| |
Clothing
|
200/-
| |
Education
|
700/- (tuition for children)
| |
Electricity
|
400/-
| |
Housing
|
60/- (rent)
| |
Social functions
|
300/-
| |
Health and Illness
|
500/-
| |
Travel/Transport
|
1,000/-
| |
Recreation
|
58/-(cable TV)
| |
Any other expenditure
|
Mobile bill
|
300/-
|
Soap/Detergent/Shampoo
|
300/-
| |
Total
|
10,815/-
| |
 Monthly income of the family
(detailed)
|
SAYAN Singh
· 5,000/-
|
Rakesh Singh
· 6,880/-
|
From Agriculture by Biplab Singh:
· 2,000/-
|
Total monthly income of the family
|  13,880 | ||
Per capita monthly income
| 2,313 | ||
Balance income over expenditure
|
3,065/-(deposited in SBI account as savings)
| ||
Socio-economic status based on Kuppuswamy’s modified socio-economic status scale
| ||
Criteria
|
Features
|
Score
|
Education
|
Middle-school
|
3
|
Occupation
|
Semi-skilled
|
3
|
Family income per month
|
13,880/-
|
10
|
Total score
|
16
| |
Socio-economic status
|
Upper middle(II)
| |
Health facility
| |
Where do you usually go to take treatment?
|
· Private sector hospital (CMRI)
· Govt. facilities are also used occasionally
|
Why Govt. facilities are not used routinely?
|
· Problem matching their free time with the availability of consultant(specialist) doctor
· Govt. sector hospitals are more time consuming
|
Schedule for assessment of environmental condition: housing, water supply, disposal of refuse and excreta
Housing:
Site
|
By lane off the main road
|
House Type
|
Mixed
|
Number of Living Rooms
|
2 (1st living room inside and 2nd room created by walling and roofing the Veranda into a Kitchen cum Living room)
|
Total area of the living rooms (Floor Space)
|
151 sq feet
|
Per Capita Floor space
|
25.16 sq feet
|
Comment on Overcrowding
|
Present
|
Cross Ventilation
|
1st room –absent
2nd room-present
|
Lighting
|
Inadequate natural light
|
Kitchen
|
In the Veranda room
|
Smoke Nuisance
|
absent
|
Kitchen Garden
|
absent
|
Drainage System Around the house
|
no open drains, Underground system drains the water into a local canal
|
Drainage
Of Household water
|
Underground system drains the water into a local canal
|
Breeding place for mosquitoes
|
Present near municipality water supply taps
|
Fly Nuisance
|
present
|
WATER SUPPLY
Source of Water
|
Drinking purpose
|
Kolkata Municipal Corporation Water Supply from Public Taps
| ||
Cooking purpose
| ||||
Washing/Bathing purpose
| ||||
Distance of Drinking water source
|
5 meters
| |||
Duration of Water Supply
|
Intermittent
|
Morning
|
7 AM to 9:30 AM
| |
Evening
|
4 PM to 7 PM
| |||
Adequacy of Water Supply
|
adequate
| |||
Collection & Storage of water
|
Water is collected by buckets and stored in drums and buckets which are kept properly covered.
| |||
Treatment of Drinking Water
|
Boiled water is given to the children
| |||
Excreta disposal
Latrine
|
situated about 20 meters away from the house
|
Where do family members including children go to defecate
|
Sanitary latrine
|
Refuse disposal
Disposal of refuse
|
Collected from each house by Hand cart and transported to KMC trucks
|
Disposal of kitchen waste
|
Waste water and sullage drains into underground sewerage system through opening in the kitchen.
Solid waste transported by hand cart as mentioned above.
|
Assessment of knowledge, practice and utilization of health services
Knowledge regarding
|
Causation
|
Modes of prevention
|
Care seeking behavior
|
ARI
|
Exposure to cold
|
Mustard oil massage before bath
|
Visit doctor
|
Diarrhea
|
Eating with dirty hands & drinking unclean water
|
Hand-wash before eating & drinking boiled water
|
Give ORS at home, if no response then visit doctor
|
Malaria
|
Mosquito bite
|
Using mosquito repellant in the evening and sleeping in mosquito-net at night
|
Visit doctor
|
Tuberculosis
|
Spreads through cough of TB patient
|
Avoid TB patient & keep him in separate room
|
Visit doctor
|
HIV/STI
|
Not known
|
Not known
|
Visit doctor
|
Serial number of wife in the family
|
1
| |
Age at marriage(years)
|
16
| |
Age at first pregnancy(years)
|
21
| |
Total number of live births
|
2
| |
Total number of abortions/still births
|
1 (3 years back)
(spontaneous abortion)
| |
Total number of current living children:
|
girl
|
1
|
boy
|
1
| |
Interval between last two deliveries
|
2yr,1m,3weeks
| |
Birth spacing/ limiting methods
(if currently used, specify )
|
· Condom
· Coitus Interruptus(currently practiced)
| |
Utilization of the following services during last pregnancy :
· Ante-natal check-up
· Tetanus toxoid
· Iron and folic acid tablets consumed
· Diet
· Place of delivery
· Delivery conducted by
|
Yes
1 (booster)
Yes( 5 months before delivery and 2 months after delivery)
Increased
Chittaranjan Seva Sadan Hospital, Kolkata
Health Personal
| |
Knowledge and practice
Topic
|
Knowledge
|
Practice
|
Infant feeding practice
| ||
· Colostrum
|
Should be given to the baby
|
Both the children received colostrum
|
· Exclusive breast feeding
|
Should be done for 1st 6 months and nothing else should be given without asking the doctor
|
Both the children received EBF for 1st 6 months of life
|
· Complementary feeding
|
Should be started after 6 months along with breast feeding
|
Started with mashed rice and vegetables from 6 months onwards along with breast milk.
|
· Feeding during illness
|
Should be done
|
Gives breast milk during illness.
|
Antenatal/Natal/Postnatal care
| ||
· Regular checkup
|
Should be done both during and after childbirth
|
Visited her doctor as advised
|
· Delivery practices
|
Delivery should be done in hospital
|
Both her children were delivered at Chittaranjan Seva Sadan Hospital, Kolkata
|
· Iron and folic acid prophylaxis
|
Should be taken if advised by doctor
|
Took IFA tables(full course not done because she had constipation and a bad taste in mouth)
|
· Tetanus toxoid
|
Should be taken
|
Received 2 injections during her 1st pregnancy and 1 injection each during the subsequent episodes.
|
· Diet
|
More food should be taken because it will make baby healthy
|
Used to eat more quantity of food during each of her meals
|
· Rest
|
Needs rest because mother becomes tired easily
|
Would lie down and watch TV or sleep for sometimes during the afternoon when the household work was done.
|
Utilization and practice of preventive reproductive health services
A) Knowledge of family planning
| |||
Desirable age of marriage
|
20 years for both male and female
| ||
Have you heard about Family Planning
|
Yes
| ||
Which methods do u know?
|
Condom / Coitus Interruptus
| ||
What is the source of your knowledge?
|
Husband/Neighbors’ wife
| ||
Do you know where MTP serves are available?
|
Yes , in big hospitals like Chittaranjan Seva Sadan Hospital and Nursing homes
| ||
B) Attitude towards family planning
| |||
1) Number of children the family desires
|
Husband
|
Wife
| |
2
|
2
| ||
2) Suitable spacing between children
|
3-4 years
| ||
3) From where are the contraceptives procured?
|
Nearby Pharmacy shops
| ||
4) Do you have any plans for permanent methods?
|
No
| ||
5) If needed will you avail MTP services?
|
Yes
| ||
6) Are you practicing any family planning method?
|
Yes (condom followed by Coitus Interruptus)
| ||
Regularity of use
|
After delivery for 1st 4-5 months Condom was used, later they practiced Coitus Interruptus
| ||
Since when
|
Exact date Not recalled
| ||
Any method used previously and discontinued
|
Condom (husband doesn’t like using it)
| ||
Any H/O induced abortion?
|
No(she has a history of spontaneous abortion)
| ||
Name of the child
|
Sweety Singh
| |
Birth history
|
Date of birth
|
24/09/06
|
Sex
|
Female
| |
Birth weight
|
3.2kg
| |
Full term/ Pre-term
|
Full-term
| |
Place of delivery
|
Chittaranjan Seva Sadan Hospital, Kolkata
| |
Birth attendant
|
Present
| |
Type of delivery
|
Normal Vaginal delivery with episiotomy
| |
Any congenital malformations
|
No
| |
feeding
|
Type of food 1st offered
|
Colostrum
|
Was colostrum given to the baby
|
Yes
| |
When was breastfeeding started after delivery
|
2hrs
| |
Breastfeeding continued exclusively for
|
6months
| |
Breastfeeding discontinued from
|
1and⅟2 years of age because she could eat hear meals properly.
| |
Semisolid/solid food supplementation started from
|
6months
| |
What type of food was given to the child during weaning
|
Kheer/Khichdi/Milk & biscuit
| |
Child feeding pattern during episodes of diarrhea/ other illness
|
Khichdi with Mashed vegetables are offered to the child.
| |
Health checkup of under 5 children:
Immunization status of the child: Sweety Singh (24/09/06)
vaccine
|
Age at vaccination
|
From where obtained
|
remarks
|
BCG
Hep-B
|
2nd day of life,(25/09/06)
2nd day of life,(25/09/06)
|
UHC, Chetla
| |
DPT-1
DPT-2,Hep-B
DPT-3,Hep-B
BPT-B, Vit-A(2)
Vit-A(3)
Vit-A(4)
Vit-A(5)
|
6weeks,(8/11/06)
11weeks,(13/12/06)
15weeks,(17/01/07)
13/02/08
09/11/09
30/06/10
27/01/11
|
UHC, Chetla
| |
OPV-1
OPV-2
OPV-3
OPV-B
|
6weeks, (08/11/06)
11weeks,(13/12/06)
15weeks,(17/01/07)
13/02/08
|
UHC, Chetla
| |
Measles ,
Vit-A(1)
|
9month2weeks(4/07/07)
|
UHC, Chetla
|
Findings on history and clinical examination including anthropometry and nutritional assessment (Sweta Singh)
Present illness ,if any
(chief complaints)
|
No
|
History of significant past illness
|
Absent
|
Anthropometry
| |
Weight
|
20kg
|
Height
|
108cm
|
Mid-arm circumference
|
13.7cm
|
Clinical
| |
General appearance
|
Normal
|
Hair
|
NAD
|
Face
|
NAD
|
Eyes
|
NAD
|
Lips
|
NAD
|
Tongue
|
NAD
|
Teeth
|
NAD
|
Gums
|
NAD
|
Glands/Thyroid
|
NAD
|
Skin
|
NAD
|
Nails
|
NAD
|
Edema
|
Absent
|
Rachitic change
|
Absent
|
Hepatomegaly
|
Absent
|
Calf tenderness
|
Absent
|
Ankle and Knee jerks
|
Normal
|
Psychological changes
|
Normal
|
Name of the child
|
Abhinabh Singh
| |
Birth history
|
Date of birth
|
07/06/10
|
Sex
|
Male
| |
Birth weight
|
3.1kg
| |
Full term/ Pre-term
|
Full-term
| |
Place of delivery
|
Chittaranjan Seva Sadan Hospital, Kolkata
| |
Birth attendant
|
Present
| |
Type of delivery
|
Normal Vaginal
| |
Any congenital malformations
|
No
| |
feeding
|
Type of food 1st offered
|
Colostrum
|
Was colostrum given to the baby
|
Yes
| |
When was breastfeeding started after delivery
|
4hrs
| |
Breastfeeding continued exclusively for
|
6months
| |
Breastfeeding discontinued from
|
Continuing till date
| |
Semisolid/solid food supplementation started from
|
6months
| |
What type of food was given to the child during weaning
|
Kheer/Khichdi/Milk & biscuit
| |
Child feeding pattern during episodes of diarrhea/ other illness
|
Breast milk given, Khichdi with Mashed vegetables also offered to the child.
| |
Immunization status of child (Abhinabh Singh, DOB-07/06/10)
vaccine
|
Age at vaccination
|
From where obtained
|
Remarks
|
BCG
Hep-B
|
2nd day of life(08/06/10)
2nd day of life(08/06/10)
|
UHC, Chetla
| |
DPT-1
DPT-2
DPT-3
|
8weeks4days(11/08/10)
13weeks(15/09/10)
23weeks(01/12/10)
|
UHC, Chetla
| |
OPV-0
OPV-1
OPV-2
OPV-3
|
2nd day of life(08/06/10)
8weeks4days(11/08/10)
13weeks(15/09/10)
23weeks(01/12/10)
|
UHC, Chetla
| |
Measles , Vit A
|
9 months 9 days
(16/06/10)
|
UHC, Chetla
|
Findings on clinical examination including anthropometry and nutritional assessment (Abhinabh Singh)
Present illness ,if any (chief complaints)
|
No
|
History of significant past illness
|
Absent
|
Anthropometry
| |
Weight
|
13kg
|
Height
|
85cm
|
Mid-arm circumference
|
13.5cm
|
Clinical
| |
General appearance
|
Normal
|
Hair
|
NAD
|
Face
|
NAD
|
Eyes
|
NAD
|
Lips
|
NAD
|
Tongue
|
NAD
|
Teeth
|
NAD
|
Gums
|
NAD
|
Glands/Thyroid
|
NAD
|
Skin
|
NAD
|
Nails
|
NAD
|
Edema
|
Absent
|
Rachitic change
|
Absent
|
Hepatomegaly
|
Absent
|
Calf tenderness
|
Absent
|
Ankle and Knee jerks
|
Normal
|
Psychological changes
|
Normal
|
Health check-up of individual family members
Identification
| |||
Name
|
Piyali Singh
|
SAYAN Singh
|
Rakesh Singh
|
Sex
|
Female
|
Male
|
Male
|
Age
|
26yrs
|
30yrs
|
25yrs
|
Presenting complaints
|
No present complaint
|
No present complaint
|
No present complaint
|
Significant past illness
|
Absent
|
Absent
|
Absent
|
Examination
| |||
Height
|
161cm
|
170cm
|
168cm
|
Weight
|
45kg
|
68kg
|
65kg
|
BMI
|
17.36
|
23.53
|
23.03
|
Pulse
|
82/min
|
80/min
|
76/min
|
BP
|
100/60mm Hg
|
110/78mm Hg
|
116/74mm Hg
|
Respiration
|
16/min
|
17/min
|
18/min
|
Pallor
|
Mild
|
Absent
|
Absent
|
Respiratory System
|
NAD
|
NAD
|
NAD
|
CVS
|
NAD
|
NAD
|
NAD
|
Abdomen
|
NAD
|
NAD
|
NAD
|
Provisional Diagnosis
|
Mild Anemia
|
Normal
|
Normal
|
Lab investigation
|
Suggested but not done
|
……………………..
|
………………………
|
Advice on management
|
Suggested Iron Tablets
|
………………………
|
………………………
|
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