FAMILY ADOPTION PROGRAM (FAP)

FAMILY NUMBER: / / / /

Village/area :

Door number :

Street name :

Name of the head of the family :

Contact number :

Alternate contact number :

Religion : Hindu / Muslim / Christian / others

Public distribution system : Utilized/ not utilized

CMCHIS card holder : Yes/No

Family composition:

Type of family : Nuclear / Joint / Three Generation

Relatio Co-
Sl. Marita Income
n to Morbidit
No Nam Ag Sex l Edu Occu /
the y
. e e * Status . . Mont
Head
# ^ ** h
1
2
3
4
5
6
7
8
(Enumerate only the members living at present in the house - visitors should be excluded) *M-
Male, F-Female, O-Third gender
#M-Married, UM-Unmarried, W-Widow/Widower, D-Divorced, S-Separated
~V-Vegetarian, NV-Non-Vegetarian, M-Mixed
.^ Educational status : Illiterate /Primary / middle school / High School / intermediate or
post high school diploma/ graduate or post graduate / Profession or honours
**Occupation: Profession /semi profession l /Clerical, shop owner, farmer / skilled
worker/semi- skilled worker / unskilled worker / unemployed/ student.

Total members in the family :

Total family income per month :

Per capita income per month :

Socio economic status (Modified Kuppuswamy scale 2021)* : Class I / II / III / IV / V

*Refer Annexure-1 for Modified Kuppuswamy scale 2021

Housing and environment:

House : Own / Rental/ Lease

Type of house : Pucca / Semi-pucca / Kutcha

Roofing : Terraced / Tiled / Thatched

Walls : Bricks / Mud / Others

Flooring : Tiled / Cemented / Mud with cow

dung
 No. of living rooms (other than bathroom and :

kitchen)

Total Floor area :

No. of Windows and Total window area :

Proportion of windows to floor area : More than 1/5 / Less than 1/5
th th

Total window + doors area :

Proportion of window + doors area to floor area : More than 2/5 / Less than 2/5
th th

Ventilation : Adequate/Inadequate

Type of ventilation : Exhaust / Plenum / Air conditioned

Cross ventilation : Present/Absent

Lighting : Adequate/Inadequate

Set back area : Present/Absent

Overcrowding * : Present / Absent

* Refer Annexure-2 for criteria for Overcrowding.

Kitchen:

Separate kitchen : Available/Not available

Lighting : Sufficient/Insufficient

Floor : Tiled / Cemented / Mud with cow dung

Fuel used : Firewood / LPG/ Kerosene/ Electricity/

Charcoal and saw dust

Smoke ventilation : Adequate/Inadequate

Kitchen platform : Raised/ Not raised (at floor level)

Provision for food storage : Present / Absent

Sullage drainage : Covered/Open

Water supply:

Source : Bore well / Public water supply /

Others

Distance of water source from house (Meter) :

Potability (Safe to be used for : Yes / No

Drinking)

Chlorination of water done : Yes / No

regularly

Proper storage of drinking : Yes / No

water

Source of drinking : Buying water / Municipal / RO /

water Others
 Household purification method of : Boiling / Filtering / RO / Others /

water None

Sanitation:

Disposal of sullage : Underground drain / Open drain

Type of : Indian /Western/Open

toilet defecation/Public toilets

Location of : Inside the house / Outside the house

toilet

Septic : Present /Absent

tank

Disposal of : Public dustbin / Corporation

vehicles / Burning /
garbage Littering in open area

Separation as degradable & non-degradable : Yes / No

waste
Domestic animals : Present /Absent

Maintenance of its dwelling place : Satisfactory / Unsatisfactory

Disposal of animal waste : Satisfactory / Unsatisfactory

Mosquito / Fly menace and breeding Site:

Stagnant pollutant water collection around the house : Yes/No

Artificial water collection around the house : Yes/No

Presence of thick vegetation favoring mosquito resting : Yes/No

Presence of fly breeding area : Yes/No

Overhead : Covered / Not covered /

tanks Not present

Health care utilization:

Type of health system preferred for major ailments : Allopathic / Ayurveda /

Siddha/
Homeopathy / Others
Type of health system preferred for minor ailments : Allopathic / Ayurveda /
Siddha/
Homeopathy / Others
Commonly used health care facility : Govt / Private

What are the ailments for which you will use homemade :
remedies? (Multiple options allowed)
Is the practice of self-medication followed in the family? If
so for whom?
Frequency of visit to the health system

Utilization of ICDS services? : Yes / No

Have you availed any of the following Social security : Yes / No (If Yes,

benefits (If applicable) Specify)

MRMBS / JSY / CMCHIS / OAP

Expenditure pattern:
 Food expenses for the family (per month) :

House rent (per month, If Applicable) :

Health Expenditure (per month) :

Transport Expenditure (per month) :

Recreation expenditure (per month) :

Savings (per year) :

Financial security : Yes / No

If yes, Specify :

Assessment of Health status of the family members (>12 years):

Health condition Membe Membe Membe Membe Membe Membe

r1 r2 r3 r4 r5 r6
Name
Age in years /
Gender
Medical and Surgical History
Diabetes (Yes/No)
Hypertension(Yes/N
o)
COPD/asthma
(Yes/No)
Tuberculosis
(Yes/No)
Epilepsy (Yes/No)
Cardio-vascular
disease (Specify)
Cerebrovascular
disease (Specify)
Disability
(Permanent
/Temporary)
(Specify)
Infectious conditions
(Specify)
Mental health issues
(If Yes, Specify)
Menstrual history (If
Female)
Other Acute/Chronic
conditions (Specify)
Previous H/O
Surgery (If yes,
Specify)
Immunization
Hepatitis (Yes/No)
COVID -1 (Yes/No)
COVID -2 (Yes/No)
COVID
Precautionary dose
(Yes/No/NA)
Anthropometry
Height (m)
Weight (kg)
BMI *
General Examination and Vitals
Pallor (Yes/No)
Icterus (Yes/No)
Cyanosis (Yes/No)
Clubbing (Yes/No)
Lymphadenopathy
(Yes/No)
Edema (Yes/No)
Oral cavity & Dental
ENT
Pulse rate / min
Respiratory rate /
min
B.P (mm /Hg)
Systemic Examination
CVS
RS
Abdomen
CNS
Personal history
Smoking / Alcohol /
Tobacco / Other
abuse (Specify)
Physical activity
(Yes/ No)
If yes, Frequency of
physical activity
1. Weekly once
2. Weekly twice
3. Weekly five days
4. Daily
Any Others History/
details - Specify
Notes: Write in detail, the existing health problem – duration, treatment taken and
adherence to drugs, complications if any, self-care etc.

*Refer Annexure-3 for Calculation and Classification of BMI

Assessment of Health status of the family members (<12 years):

Health condition Child Child Child Child Child

1 2 3 4 5
Name
Age in years/ Gender
(Specify in months for children < 1
year)
 Birth history
Mode of Delivery
Institutional delivery (Yes / No)
Birth order
Birth weight
Exclusively Breastfed up to __ months
Developmental History
Delayed Milestones (Yes/No)
If yes, specify
Disability/congenital anomaly (Yes/No)
(If yes, Specify)
Medical and Surgical History
Acute/Chronic conditions (Specify)
Any H/O Surgery (specify)
Frequency of illness in last 1 month
Frequency of hospitalizations in last 6
months Specify with reason.
Anthropometry
Height (cm)
Weight (cm)
Mid arm circumference (cm) (2 -5yrs)
Head circumference (≤ 1 yr)
Chest circumference (≤ 1 yr)
Abdomen circumference (≤ 1 yr)
Immunization History
Immunized up to age* (Yes/No) -
Attach Immunization card
Notes: Write in detail, the existing health problem – duration, treatment taken and
adherence to drugs, complications if any, self-care etc.

*Refer Annexure-4 for Immunization schedule

Assessment of Maternal and Child Health (MCH) and Family welfare:
 Any Pregnant Women in the Family : Yes / No If Yes fill up the AN/PN
form

Any Women delivered within Two Months : Yes / No If Yes fill up the AN/PN
form

Any Eligible couple in the family :Yes / No

If yes, Any mode of contraception adopted? :Yes / No (Specify if yes)

_____________

For children< 5 years, whether fully immunized? : Yes / No (If No, Specify the
* missed vaccines) _____________

1. For children< 2 years, Do you continue regular Yes/No

feeding during bouts of sickness?
(Diarrhoea/ARI/Fever)
2. In case of sickness of child where do you take GH / Primary Health Centre /Sub
the baby? Centre / Private hospital /
Traditional healers
3. Have you tracked the growth of your child <3 Yes/No
years with growth chart? If yes, Attach a copy

No. of birth in the last year M: F: O:

Whether registration of Birth done? :Yes / No

No. of Death in the last year M: F: O:

Whether registration of death done? :Yes / No

Any Maternal Death (< 12 months) :Yes / No (If Yes, Specify Age and
Cause)

Any Still birth/Abortion (< 12 months) Yes / No (If Yes, Specify

Gestational Age and Cause)

Any Infant death (< 12 months) :Yes / No (If Yes, Specify Age and
Cause)
*Refer Annexure-4 for criteria for fully Immunized status
Ante-natal / Post-natal Form:

Should be filled for any women who is AN/PN Mother during any of the visit

AN / PN related details Member Member

1 2
Name of the Mother

Age of the Mother

Age at marriage

Age at first pregnancy

Obstetric score (GPLA) *

LMP & EDD (For AN) & Date of Delivery (For PN)

Gestational age (For AN)

Whether the current/last pregnancy registered? (Yes/No)

Number of ANC Visits taken for the current/last pregnancy

Whether received MCP card? (Yes/No)

Number of doses of Td received (0/1/2)

Number of IFA tablets received?

(Nil/ <30 / 30-60 / 60-100 / >100 )
Choice of place of delivery (AN) / Place of Delivery (PN)

AN Complications during the current/last pregnancy

HT / DM / Severe Anaemia / Bleeding / Others (Specify)
Mode of delivery (For PN, Normal / LSCS / Assisted)

Birth weight of the newborn

Whether any pre-lacteal feeds given? (Yes/No)

Time of Initiation of Breastfeeding

 Number of PN Visits taken for the last pregnancy

Is PNC obtained from health care professional < 2 days of

delivery for the last pregnancy (Yes/No)
PN Complications during the last pregnancy
Severe Anaemia / Bleeding / Sepsis / Others (Specify)
Whether any mode of contraception adopted post-delivery (For
PN) (Yes/No, If Yes, Specify)
Whether received benefits under MRMBS / JSY (Yes/No, If
Yes, Specify)
Weight of the mother
• At the time of Conception:
• At the time of Delivery:
• Total Weight gain during pregnancy:
*Refer Annexure-5 for Obstetric score

Follow-up Report:

During each visit to the family,

• Mention Positive examination findings, if any, during the visit

• Mention the Lab values (Hb/RBS/FBS/PPBS) if any

• Update vitals (BP, PR, RR) and Anthropometry (Ht, Wt, BMI, MAC, HC, CC and

AC whatever applicable to the age)

• Mention outcome of AN Mother if any

• Attach Growth chart for children<5 years and track their Weight for age, Height

for age, Weight for Height as per WHO growth standards*

• Mention specific advice given to the family members, if any

*Refer Annexure-6 for WHO Growth standards

 Name of the Family Member Name of the Family Member Name of the Family Member

Visit

8
9

Name of the Family Member Name of the Family Member Name of the Family Member

Visit

7
8

Name of the Family Member Name of the Family Member Name of the Family Member

Visit

6
 7

Consolidated Family assessment Report:

Solution/Intervention. Include
National health program where
Domains Issues identified ever relevant
Demographic
structure
Socioeconomic
factors
Lifestyle and social
aspects
Environmental
aspects
Health system
related issues
Cultural factors and
family influence
Psychological
aspects
Any other Threats

Health problems
Diagnosis Whether on
identified in the
treatment
family
 Adherence to Whether
treatment (Regular / under
Name of the Irregular) control
Member (Yes/ No)
1.

2.

3.

4.

5.