Post on 26-Dec-2019
transcript
tJ~(Nam ) /: o~ 1>6J
~~~J(Age)
~C)~~ -!)~~(X) (Nam of th Baby)
~~ :O~lVO~
:'JwotS @)23-i!o ~~tDD~~) : -~~~~
~o~e.>OSJJ
Mother Photo
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~cs, (Name)/s.ofJ ~~ : ----------------
:>~g.":
~(Occupation)
~~~= ----------------------------------~t>o (Community) : SC I ST I BC I OC I Minority
~~" -QCS,~~ : -----------------In case of temp Migrants/Beggars/Nomads OSoiG IG~~tl.»w I 4)~~ I «GoooCS sofileJJ
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3
4
il~ ~cs~~ I ~~oS~ I e:cS~ g)oS~~eX) (History of Past Pregnancy)
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~~~~~= ------------------------------------e
~Q11: ----------- cSo"~~ ----------
~--------------------- 1 --------------------~
UMP EDD Hei.ght HIV HbS Blood Examination ~of a~lStme.»
~~6 ~~~ ·so~J ~~e>RlCS ~R ·~~ A g. group.;RH cvs IRS ae ae K:>oc ~~68ebe» -. ' ~ "
' ,
~~~ ~tb~ ~~dS;)oQ a~~ ~e~ ~GScS~~
Date Weight I
Hbo/o Urine ·Oedema I Fundai iHeight/ T.T. Injection B.P. ' FHS 'Other .Remarks & Date of 6e m&~ ~.~. ~~ftc..~ ~l!1o'>8~ SOf!JOJO~el) I !Presentation tJ. tl. ao~~~ Symptoms Treabnent !Next Visit:
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I ~.~~.~o. ~= ~~& ~& : Cj
I ~~~~ ~6~ l))~o~)fS G~~l9 ~~tS~~ 1 fSo~~~ . fSoti~~ . . . .
~~@d 13cSO)e)~c6 6e :_ ~ · @)~~ .~~<:SDo~ ~o@)E>otS~e)~cs ~ g)~cStme» ~ 1
! CHNC ---- - - -
~3s~ ~~~~6~ ra~:JoiS~e.1~~ <!P .t~c.» (Check list for Special Care)
~ ~oO ~~(S'CS .SO~~~ ~& ~" ".SJ~cSC119 ~~e»"a' .SOl ~cm~~oSi3~.
~~~6 ~~~ CSQi,dS:>oQ High Risk Very High Risk
1. Instrumental delivery ~~~o~ @S~oSo <esa.J~.J)
2. Eclampsia I~~~ 3. PPH I CS~~cS~ 4. 3 or more Abortions I
D 5. Previous Pre tenn delivery ;5C)U) ~0~~ ~oa sv~ e6l/UtJ ...
D 6. Still birth/Neonatal death I D ~~ .s~~ ei~Oi5lt>/so(6)
D
D
[] 4!VOJJ~ ii]Q(Sodi~ ~CS~oi5:lt> 7. Caesarean Section I ~2:18<:1il~ 0 8. Other Obstetric Complications 0
3 ~o~ ~~6.~ X~@o~~Ol
------ - ~~" ~~ ~~~oe 1. Primigravida under 15 years 0 l . Premature labour D ~~~ K~~ 15~o11d~ ~ot» ~ oS»oa ~ot>Ol oS6ne>
2. Primigravida above 35 years I D 2. Ante Partum Haemorrhage 0 @)~~ K~~ 35~ou ~16 ~<6>~ tmotSJ 6~@o~o
3. Age above 40 years I ri~~ ~d:»~.J 4 0~011 "Ec6
0 3. Abnonnal Presentation 0
4. Pregnancy after prolonged 0 infertility (1 0 years) CDVO ~OIIe.> {10~011) ~O~~eiS~ ej~fj x~~6m
5. Fifth Pregnancy or greater O 5 a[JQ e!>cf.i~oD ~~iS ~~ ~~0~~~~
6. Height less than 145cm K~)~ ~~ 14 5 ~o. fl>. ~o13 d!f>J.OS
7. Systemic Disease eg,soD~ 6J1ldal
8. Th~eatened abortion ~~~~0
9. Other I Minor Complication ad6 ~~~a~
D
0
0
0
~o~o ~~~6m ~a
4. Intra Uterine Growth Retardation ~0~0 ~6.lK>6e) e5~~~~
0
5. Multipule Pregnancy 0 ~~e.>ex> 80" eDoei~oD ~~J.,OS
6. Hydramnios a~fJCSl ~~~ ~o~t.J
0
7. PIH 0 K~~ ~a.»otl (S~~t» ~!1:JJ,~~tJ
8. Severe Anaemia 0 b@S~c6 6~boc6~
9. Cardiac Disease KJoa ed~al
10. Diabetes Mellitus (6:,~~~0
0
0
11. Gestation exceeding 42 weeks0 42 eiJV6~a~ :OoE.NO ~~~o so~~~t.Jo
NOTE :? e:s~ ~g ll~ ~~ii>o iltJ~e a§ :5 ~e~ Lr.S~~ ~c: ~ rs~~a~.
~~------------------------ 3 ~------------------------~
St~({u.) GO»~ ae & i-J~Cl»o ~~~ ~ ('tJ:Jf'l/e!j~) Date of Delivery & 'Time
~l;P6ca~ APGAR 1'mrn Is Minutes Normal
~/Weight ®~~6m~ (Abnormal) : lnstrumentaUCaesarian SD~J @)a~ (Place):
~ct\@oc5ofn)~c5 r~.'t.:/tlo/ ~~ a~o:sve 1,t},~o:> (Conducted by)
ii3oCD ~ot:;~oC" ed~o -Abortion/Still Birth/Premature t>o~!:i~ Stamp
CJOVo~ ~orS~~ (Post Natal Care)
l~ /?}~ a~ ffr=> 7tJ /?}rot' 1 2~ ~60 3~ GlDCSO ~ c:F6o 6~~60 , - . ·"
1. tS~~cs~ -2. ~e
R ~~~t.ll
4. a'omp I 5. lS~&i6e.D !
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7. 6~l?'iSifu> I (~~)
s. e;srstm r I
r 1
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S).~. ~o.:
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7. sa~~
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9. :la~~e» (~et>~~}
1 o. omo~ :>tS~;6 11. G))e>~
12. G:POfi)elJ
13. ~6G5DcD
~ I Not Willing ~6 I Willing
91'6Cilo I Reason ~wg:D/c5@~ I TubeNas.
:sG~ ~{!ieD I Oral Pills
Gl.~.~. ~. I IUCO
~oeG~J I Coeloms
a~tS I Others ..... ___________ 5 __________ _...
GIRL : Weight-for-age • Birth to 5 years (Aa per WHO Child Growth Stllnderda)
.a: ~~~ ~ l»eo.O - ~~ 5 (S~
~ ~HH~~++~~~~~++~~~~ j,~~~~~~P+~~~~~~~++~
!2)·~· ' ''1011 51').
I 2 J • ! 6 1 f t ~ I! 4Y!
E I 1 3 A ! I 1 t ! 10 II 11'
i Aet (~....,lllllltllllllrenl ~ ~~@{(ilQI~)
+Care During Illness+
+ •~ottto"' e~~ b~f~VJtS tl\~~Ul + Ensure equal care for the girl child
6
Fever • 11 high leY()( r.»;o 1t10 tlllld
10 lila I'INIIh OQntrO
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BOY : Weight-for-age • Birth to 5 years (Aa per WHO Child Growth Standards)
.s!bi: ~ ~ ::s~~~-~!i~c:: cr.:.::.e.~::.)
• c-66 ~,.) ~ )9~~t7J"~u, ... ~ ~ ~10 ~ ~. ~'~ttl w. ~orQ ~ 16-45 ~ttl'tl) ~Cl!:b ~ ~w ~~ t.!S ~~ ~~~ •
• ~t:locS~~~~~~~
;s!l;:~ ~ ~~!S~ ( .tl.O.~S) ~ .,~o«S ~ ~ ~. -86l ~tJt.ll K~6l!o, btJl! @'d~&5C:o
• ?>~~ ~~w Q-&.:SC:o, m~d ~OD' ~ ~ ~~ ~"-'? ~~ ~ ~ -~-x_6lc;::.) ~0 • ~f$Jd'«; 6~ ~ ~~ ff'-t~ ~ ~~0
ii I I J t S 6 I I I 1, .; Age (completed weeks, months and yeara)
~~ ~ ~. ~tl) 1: ~JO"tl)l
7
B.C.G.
OPV-1
~Q :0~~~ ~sv~-~~tJOtX) ~ R. I ~ ie - (Due a o... gtven)
-~~~ • L~tS~o eaentS~~
OPV-2 OPV·3
Vitamin A Vilam1nA OPT -~&
*lr:bJlSoS ~e> &tSe.u - 6 ~oe.>~ e.,~~e ~go oo~~e C:~e.u
~------------------------- 8
FORM N0.5
~~a.r~~tm GOVERNMENTOFANDHRAPRADESH
.cs;S ~ ~~tm Birth Certificate
..................... ? ............... ···---- ........ .,.._.....,. ........ .
II..S .-~ 1:. I" tl(t61clt~ llif Rll1hio -.1 .... Act 1969adltul8 13 f ~Alliin I'TIIk.!ih Rqto~twtum o(tltn~ IUld Llml!l ltllln !0'1111
~~~ ................................... !!q! ....................................... ~~
..... ' ............................................ (~:;)' ~~~) ~~ .S,6c; ~;o ~~~ ~Oo!Ji{)
-~ ~ ~.lfoe ~~ IM-~~ ~'1!>~6~~.
nus 1s to CC'Itlf) lbat the followiq mformallon bas been taken from the onginal record of buth, which 1s m the
register for •....• - ...................... -.... -.. (local area locaJ body) of Mandai ................................... .
of Dastnct .......................................... _ ..... of State Andhm Pradesh ~ Name
~
Sex
~~ Date of Birth
.. .. .. . .....
~~ Place of Birth •
~1a& Name of Mother .. . ~~ Namt of father ·
~~~4~~ Addresl of lhe parents at the tune of 81nh of Child
~~
Reg1stration No. _ .. - .. -·-·".. . _
~-Date of Regasttation .. ____ "-
~ Rermarks ..... --·---·"~--.. ·-~-~·-~ 11'6~~
Date of Issue
4~~~~ P~tA~sofP~u
.6 ~ -o.-o ~-~ tDOd:m ~~ Sagnature of the assuing authonty and addlftS
~I Seal
~~«'s~~o~ ~4)o~ @&tr:J~~~
1) ~ ~ .. ~ /(JSY}
~·~~ ao ~"~ ~. - "l!o~~~~ ~0"~~ 1 2 3 4 5
~"~ . ... .
3) ~ ~ ;S4Sifo ~ (G.C.P.S.)
(~-~ ~ 6:J. ~ ~ ~ !btDom ~h ~~. CJICL~ <~li'-~~ ~. 24,000/-~ ~· ~ IP'otr~ C7ldbo 6:1-11 20.000/-)
~.,.0~~·
·-~~~~=
ANM ~'~ (Signature)
~~~ (Signature)
;$~~ (Signature)
~-------------------- 10 --------------------~
~I ~/Diagnoais t>UJ I Treatment ~·I ~o/ Date
Q
~.e'll~ Sig.
~--------~------~ 11 ----------------~
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