Mother Photo

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!)~~(X) (Nam of th Baby)

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~(Occupation)

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~t>o (Community) : SC I ST I BC I OC I Minority

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In case of temp Migrants/Beggars/Nomads
OSoiG IG~~tl.»w I 4)~~ I «GoooCS sofileJJ

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(History of Past Pregnancy)

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~Q11: - - - - - - - - - - - cSo"~~ - - - - - - - - - -
~--------------------- 1 --------------------~
 UMP EDD Hei.g ht HIV HbS Blood Examination ~of a~lStme.»
~~6 ~~~ ·so~J ~~e>RlCS ~R ·~~ Ag. group.;RH cvs IRS
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Date Weight B.P. ' Hbo/o Urine ·Oedema I Fundai iHeight/ FHS T.T. Injection 'Other .Remarks & Date of
6e m&~ ~.~. I
~~ftc..~ ~l!1o'>8~ SOf!JOJO~el) !Presentation
I tJ.tl. ao~~~ Symptoms Treabnent !Next Visit:
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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 D 5. Previous Pre tenn delivery D
~~~o~ @S~oSo <esa.J~.J) ;5C)U) ~0~~ ~oa sv~... e6l/UtJ
2. Eclampsia I~~~ D 6. Still birth/Neonatal death I D
3. PPH I CS~~cS~ D ~~ .s~~ ei~Oi5lt>/so(6)
4. 3 or more Abortions I [] 4!VOJJ~ ii]Q(Sodi~ ~CS~oi5:lt>
3 ~o~ ~~6.~ X~@o~~Ol 7. Caesarean Section I ~2:18<:1il~ 0
8. Other Obstetric Complications 0
------ - ~~" ~~ ~~~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 0 3. Abnonnal Presentation 0
ri~~ ~d:»~.J 4 0~011"Ec6 ~o~o ~~~6m ~a
4. Pregnancy after prolonged 0 4. Intra Uterine Growth Retardation
infertility (1 0 years) 0
CDVO ~OIIe.> {10~011) ~O~~eiS~ ~0~0 ~6.lK>6e) e5~~~~
ej~fj x~~6m
5. Multipule Pregnancy 0
5. Fifth Pregnancy or greater O ~~e.>ex> 80" eDoei~oD ~~J.,OS
5 a[JQ
e!>cf.i~oD ~~iS ~~
6. Hydramnios 0
~~0~~~~
a~fJCSl ~~~ ~o~t.J
6. Height less than 145cm D 7. PIH 0
K~)~ ~~ 14 5 ~o. fl>. K~~ ~a.»otl (S~~t» ~!1:JJ,~~tJ
~o13 d!f>J.OS 8. Severe Anaemia 0
7. Systemic Disease 0 b@S~c6 6~boc6~
eg,soD~ 6J1ldal 9. Cardiac Disease 0
8. Th~eatened abortion KJoa ed~al
0
~~~~0 10. Diabetes Mellitus 0
(6:,~~~0
9. Other I Minor Complication 0 11. Gestation exceeding 42 weeks0
ad6 ~~~a~
42 eiJV6~a~ :OoE.NO
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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~
Normal
APGAR 1'mrn IsMinutes
~/Weight
®~~6m~ (Abnormal) :
lnstrumentaUCaesarian SD~J @)a~ (Place):
~~ a~o:sve 1,t},~o:> (Conducted by)
~ct\@oc5ofn)~c5 r~.'t.:/tlo/
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

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~ 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
_I _
....._ _ _ _ _ _ _ _ _ _ _ 5a~tS _ _ _ _ _ _ _ __...
Others
 GIRL : Weight-for-age • Birth to 5 years
(Aa per WHO Child Growth Stllnderda)
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!2)·~· ' ''1011 51').
j ,~~~~~~P+~~~~~~~++~

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Fever
• 11 high leY()( r.»;o 1t10 tlllld
10 lila I'INIIh OQntrO
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+Care During Illness+

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i Aet (~....,lllllltllllllrenl
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+•~ottto"' e~~ b~f~VJtS tl\~~Ul +
Ensure equal care for the girl child
6
 BOY : Weight-for-age • Birth to 5 years
(Aa per WHO Child Growth Standards)

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.; Age (completed weeks, months and yeara)
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-~~~
B.C.G. • L~tS~o eaentS~~

OPV-1 OPV-2 OPV·3

Vitamin A Vilam1nA OPT -~&

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~------------------------- 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{)

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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~~ 4~~~~
Addresl of lhe parents at the tune of 81nh of Child P~tA~sofP~u

~~
Reg1stration No. _ .. - ..-·-·".. . _

~-
Date of Regasttation .. ____ "-
.6 ~ -o.-o ~-~ tDOd:m ~~
~ Sagnature of the assuing authonty and addlftS
Rermarks .....--·---·"~--..·-~-~·-~
11'6~~ ~I Seal
Date of Issue
 ~~«'s~~o~ ~4)o~ @&tr:J~~~
1) ~ ~.. ~ /(JSY}

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~·~~
1
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- "l!o~~~~ ~0"~~

2
3
4
5
~"~... ..

ANM ~'~ (Signature)

~~~ (Signature)

3) ~~ ;S4Sifo ~ (G.C.P.S.)
(~- ~ ~ 6:J. ~ ~ ~ !btDom ~h
~~. CJICL~ <~li'-~~ ~.
24,000/- ~ ~· ~ IP'otr~ C7ldbo 6:1-11 20.000/-)
~.,.0~~·
·-~~~~=

;$~~ (Signature)

~-------------------- 10 --------------------~
 ~I ~/Diagnoais
Q
t>UJ I Treatment ~·I ~o/
Date ~.e'll~ Sig.

~--------~------~ 11 ----------------~
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