INTEGRATED CLINICO-SOCIAL CASE STUDY

DIABETES CASE
Name:s Jhani Tani Age:55
Gender: ernade Education gh gtà
Income: Nfl
Occupation: Houe oige
Religion: idn Caste: B
Contact number:
Address hingm
Nearest health facilit: Gqusumart tosyd,Distance in km: 2 m
FAMILY DETAILS (Expand if more mmebers)
SN Name Age Relation| Marital Education Occupation IncomeHealth
/sex to HOF status
status
Moiet
Jhanei Rar 55|F wie gth DM
Daugd Moried
Soxn 31 Bon-in-b MameDhosmThaoroact 00o
Guanteon

Type of the family: Nuclear/ Thrèegeneration/ Joint

Pedigree chart of family:

CHIEF COMPLAINTS Nodomil toin or lusok f o

H/o presenting illness: Pertaining to DM (Ask mainly regarding hypo/hyper
glycemic symptoms)

70
 vOuever been diagnosed as diabetic? Ves
type: D -
specify
Ifyes,
When, where, how was
it
diagnosed? Which symptom made him seek
Describe onset and progression in detail. consultation?

ordidiics
xdomiod

sdin Sha whieh

71
TREATMENT HISTORY
Places of treatment/Type of treatment received/Treatment drugs details
Name/Dosage/Frequenc /Duration:\alAmra hopta |aa bities Mohromi
Side effects of drugs:Nil
Number of consultations: l
Frequency of follow-up/investigations: \0
Referral:
Health education - Diet/ Follow-up investigation/Foot Exam/Foot
care: Following diabetic diet or not: No hoog
H/o use of other systems of medicine or
H/o hypoglycemic episodes, frequency and
non-prescribed drugs: No
treatment:o
History of diabetes-related complications
Type? Who noticed? Howdid it manifest? What was he
advised?

IMPACT OF DISEASE
For each visit
Consultation fee:a
Investigation:
Treatment:yroe
Travel: N
Nutrition: ona
Extra care:Aaiesd id rodsosbe thuygind aiy
Loss of wage/work:
30 mins to
Loss of
QOL/Stress/Tension/Pain/Guilt:
Satisfaction with services: (ottslg
No
tieiet

72
pAST
HISTORY
diatsla
hlomo hodansion
No

No

PERSONALHISTORY
(urrentlysSmoking any tobacco products, such as cigarettes, bidi? Yes/N6
fyes, mentionduration:
frequency:
(urrently usinganysmokeless tobacco products[snuff, chewing tobacco, betel]:
Ves/No,Vfyes,
mention duration: frequency:
ConSuminganalcoholic drink, beer, wine, or spirits? Yes/No
amount per drink: ml duration:
f ves, average
Slepappetite:boal
frequency:
Noal
Rwel and bladder habits:
hgiene:Gan
allergy/reaction:1y
HStory of drug
Personality Type:
Stress:yo

PHYSICAL ACTIVITY

Does your Work related activity Travel Recreational

work
involves any Vigorous Moderate Travel to
of these intensity & from
Sports, fitness
intensity activities
activities for [heavy Mild
[brisk walking, intensity places
at least 10 loads, [walking,
carrying light (walking cycling]
minute digging, loads] or cycling]
contNumber
inuouslofy const.work]
days/ week
Time
spent on
atypical 15 Trinul
day
Total
105 minusl

73
 MENSTRUAL HISTORY

Age at menarche: H Duration

Age of
of each cycle: 20
doe
Regular or irregular cycles: haqdo attainment of
Postmenopausal bleeding: No H/o PCOS:NO
menopause: S2
MARITAL HISTORY
R0 Child
Status/Duration:
OBSTETRICS HISTORY
n
birth/Contraception: iidithd
G/P/A:i History of GDM: Wo
Delivery of baby >4 kg:No Recurrent fetal loss: No
FAMILY HISTORY

History of consanguinity: AAsrd

Family H/o DM/HTN/CHD/CVA/Kidney diseases: o
List of morbidities/complications in familyNo
Familymembers screened for HTN/DM: ys.
Family relationships
h o n is
-

Stress on family: Abasro

Emotional support: Goo
Response of family towards illness:
who accompanies to &oe
Impact of disease on hospital/getting drugs:Tto
Intra-familial relationship: e
SOCIAL HISTORY

Societal/Neiwithghborhood
Interaction Rel
society: G
ations: Aiins
Response of society towards
Participationinin person: Gc
Involvernent
Impact of festivals/marri
social groups:\
disease on
ages/social
dmas
activities: G

Inter-familial relationship: s i np
74
ATTITUDE TOWARDS DISEASE
Attitude towards present illness:Tm wgulao madiction edam ro
Stigma: o

OCCUPATIONAL HISTORY
Current and previous: HonSiige
H/oof exposure to hazards: No
Unemployment: reason and duration:
Attitude towards job: Gd

ENVIRONMENT

Housing
Type: Kutcha/Pùcal Semi-pucca Rented/oWn
Number of rooms: 2
Area: So (Sq. feet)
Flooring: Tiled/Cemented/Mud and cow dung Walls: Brick/Mud/Thatti
Roofing: Thatched/Tiled/ReCAsbestos sheets Lighting: Adequate/Inadequate
Ventilation: Adequate / Inadequate Cross Ventilation: Adedate/Inadequate
No of persons per rooms: Overcrowding: Present/Absent
Source of water: Mnioia Storage of water:\ooe vess
Nature of supply: Continúous/Intermittent
Purification: Boiling/Straining/ Fitet/Purifier
LPG/Kerosene/Others
Kitchen: Separate/ Living room/Outdoor Fuel: Biogas/
Utensils:Cean/Food items covered Drains/Septic tank:
collection/Others
Refuse disposal: Covered bins/Open dumping/House
latrine/Open
Excreta disposal: Houséhold latrine/Public
eating/After ablution
Hand washing:Wittsoap/Without soap/Before
Animals/Pets: No T I n Mosquito/ Rats/Others: rnart

75
Economic conditions

Total family income: Po o

Expenditure on: Diet/ Medtcal care/Recreations/Education: 5 i00
Saviigs/Debts: 0.o
Ration card: Color/Services: on
Aadhaar card: Y
Family strain due to economic conditions: Aola o rarage
Welfare schemes
Food through PDS: yes Gas/Cylinder/Stove/Kerosene: ys
Old age pension: No Other benefits from social security: -

DIETARY HISTORY: (24 hour dietary recall method)

Type of diet: Ve Mixed Staple diet: Ria
Record all food and drink eaten on the previous day between midnight and
midnight.
Timings Food items with quantity Calorie Protein
Breakfast

Sortos-\0
Brunch

Lunch

12K26 8
Tooorn \ag
Evening

Dinner

Others

76
 Radio-femoral
Temperature:
delay
Pulse SkiBuilt/Nourishment:
lcterus/Cyanosis/Clubbing/Pedal n Orientation
No Calm,condition
JVP:Pallor/ EXAMINATION
Patient's
general GENERAL
(fasting?):
CustomsNoFood Habit Fried Most
Salt/Pickles/Papad/Chutney/Salty Total In In Fruits Protein
intakeCalorie
intake
rsalispedis/post
carotid/brachial/
tibial) Felt Vessel
examination a a
typicaltypical
equally rate, - conscious beliefs/Food
taboos:NO of commonly
foods and
wall eating
rhythm, 3s9n to intake: week, week,vegetable
in AsaonQ
thick time, and outside: used
all (for on on
(atherosclerosis)
peripheral cooperative:4s
volumeacanthosis place N) CC0ooa
oil: how consumption
how
ocoiora Vegetable lbbo o
Recommended
and many many
8
pulse
yesbado|min nigricans person: bôlt days days
processed
oil/Butter
No do do
77 onoroo roUiha
edema/Lymphadenopathy
/Koilonychia you you
and
foods: eat eat intake
Actual
insulin
palpation:
Noma
Thyroid Frequency or
ghee/Margarine vegetables fruit?
\qudnorma
injection o5OTo
per
sites): week: 2 Days
/0ther: Deficit/Excess
Ora
Ab3n
Serving/
Amount
i
vola
 Breast examination:
Foot
Examination
Examination
Abdomen: of
amination: Central
Auscultation:
Percussion:
Palpation:
Inspection:
Cardiovascular
examination
system
Auscultation:
Percussion:
Palpation:
Inspection:
obromalitbg
dstectsd o EXAMINATION
SYSTEMIC gOom
Respiratory
System
circumference/WHR:Waist
Anthropometry
Ht/Wt/BMI:156Tongue/Oral
hygiene:
Pressure:\20hommtaG
Blood
Nervous
No
of
both
System
knee

raltby joints: examination: m

Si,S2hoo
bHKa

78
262

datt
rate/Type:lb
Respiratory

Troracondonio

\tmin
 Advice Followup
examination:
Treatment:Taiand Advised:
INVESTIGATIONS
Already LAB PROVISIONAL
DIAGNOSIS
COMPREHENSIVErom ininang FINAL examinatlon:
system
other
on oiqiniov\iqe CLINICO-SOCIAL
diabetes
done:

MANAGEMENT \
self
care
ie DIAGNOSIS nh01
practices: on
hemin PLAN (9YYn)
Mn
79
iog Tharai

n Yhni,
htim
Ko
uow
ise
qulh
qn

ait {
areod
eon DrlessnSS
COMPLAINTS
H/oCHIEF Pedigree Type 2
Age/sex
Name SN
Address:hani
FAMILY
facility:
Nearest
healthReligion:
irn Gender:
Mole
Ssn nloNo presenting Bmvino (EName:
Occupation:fan
of
the DETAILS
chart
\inein Mr.
family: 7n
illiness: of
G
(Expand
family:
Nuclear/Three dibnmanigm
HOF to INTEGRATED
Relation
Ayoxrdy BargDorein if
more

status family HYPERTENSION

CASE
generation/ Marital CLINICO-SOCIAL
STUDY
CASE
members)
80
Education
oTroh
Joint ContactCaste:
Distance
number:
h2o00Cnsion) Education
Income: bAAge:6T

Occupation
osere r in
km:
HYhn

Income
gt7i2022
status
Health

TREATMENT
HISTORY consultation?
Describeor Have
If
Consultation
fee:te treatment
For History
each
visit
re DISEASE
IMPACT OFand Historyof follow-up
Referral:
H/o Health
Who Following
Anyhypertensie oftreatment/Ty
consultation
Frequency Number ofSide Placesof yes,
Satisfaction Treatment:|Ro
Nutrition:
Ss
withser Lossof
QOL/Stress/T HoInvestigation:
Losscare:
Extra Travel:
je:iis
use effects you
of history noticed? when,
education ever
wage/work: of
Coxormu other DASH where been
of of
How drugs:
admissi
syste diet anddiagn
did Die -
 Satisfaction
wage/work: Loss
of
care:
Extra Travel:
Treatment:\Ro
Losssaed
of Nutrition: Hoi Consultation
Investigation:freo
fee:\S visit
eachIMPACT
For OF Any
DISEASE History WhoHistory Following
H/o Health
Referral:
consultations:
FrequencyNumbereffects
ofSide ofTREATMENT
places
HISTORY consultation? yes, IfHave
history noticed? use
Tension/Pain/Guilt:NO
and of education
of of when, you
with hypertension-related other DASH treatment/Type
of ever
treatment of How
admission follow-up/investigations: Describewhere been
services:
did
systems diet -
Dièt/or
of to it
not?
diagnosed
and
manifest? Follow-up
of onset
Goo, other
hospitals of how
medicine 4es
treatment and it
disorders: complications was as
What
nvestigations/Physical progression a
because or hypertensive?4
diagnosed?
81 non-prescribed
was b received:
y trorh
of he
advised? in
HTN Which
detail.
tox
complication:
uxqsU drugs: D symptom
activity/Addictions
Gibordanida
Ygovmin
dos No
made
whups
LIMAOAD ,
him
let seek
Fo
tra
sd
 83
\oi jotowards
b: Attitude 82

ieduration): and(reason
Unemployment
hazards: exposure
to H/o man sFoJm,
of previous: Current
and
HISTORY
OCCUPATIONAL
iaM StNo
igma: bleeding:
Postmenopausal
0tivQ illness: present towards Attitude
menopause: attainment
of ofAge cycles: irregular Regular
or
DISEASE TOWARDS ATTITUDE cycle: each Duration
of menarche: at
Age
HISTORY MENSTRUAL
shtnsd relationship:
Not Inter-familial disease
on Impact
of
Total
groups:it social
Involvement
in
activities:ennt
festivals/marriages/social Participation
in typical aon
day
Ged person: towards society Response
of spent Time
society:MArt Interaction
with 1 days/week
Number
of
Societal/Neighborhood
relations:G cycling] cycling] or loads] work]
HISTORY SOCIAL [walking, [walking lightcarrying ConstruCtion continuously
activities places walking, digging, loads, min 10 least at
relationship:
oha Intra-familial on disease Impact fitness from intensity
& [briskintensity [heavy intensity activities
for
wit2hospital/getting
drugs: accompanies
to
of
who Sports, Travel
to Mild Moderate Vigorous these ofany
illness:Positive towards family Response of Recreational Travel actiity related Work
involves
your Does
Work
Gosupport: Emotional ACTIVTY PHYSICAL
Nona family: Stress
on
relationships Family NO
Stress:
morbidNonaities/family:
compl
y2s HTN/DiM:cations Screened
for members Family Type:
Personaiity
DM/HNoneTN/Cdiseases:
HD/CVA/Kidney in
ofist allergy/reaction:N drug History
of
oreargaro consangui
Non nity: H/o Family GdHygiene:
Histof
ory NoTmm habits: bladder
Nomd
Sleep/appetite:
and Bowel

HISTORY FAMILY frequency: duration: ml, drink: amount

per average yes, if
Preeclampsia/Eclampsia: Hisof
tory Yes/No spirits? wine, beer, drink,alcoholic
or Consuming
an
birth/Contraception:2
Chile G/P/A: betel): tobacco, chewing
frequency: duration:
(snuff, products tobacco smokeless
mention
any usinCurrently
g
yes, Yes/Ne,
If
Child HISTORY frequency:
o OBSTETRICS
Status/Duration:
36 Yes/No cigarettes,
bidi? as
products,
such tobacco
duration: mention
smoking
any Currentiy
yes, If

Manid HISTORY MARITAL HISTORY PERSONAL

ilys

HISTORY PAST
 85
84
Chtn foods:processed Papad/Chutney
/Salty Salt/Pickles/

Total security:
No social frobenefits
m Other pension:
es age Old
vegetables eat you do
days many how week,
on typical aIn Gas/Cylinder/Stove/Kerosene:
o No PDS:through Food
fruit? eat you do
days many how on
week, typical aIn schemes Welfare
Amount
Serving Days consumption vegetable and Fruits
\onaconditions: economic todue strain Family
H18 card:seeusd Aadhaar
intake Protein Gxcsn
Color/Services: card: Ration
intake Calorie Savings/Debts: -
Deficit/EXcess intake Actual Recommended care/Recreations/Education: Diet/Medical Expenditure
on:
00 income:
H2 family Total
conditions Economic
Mosquito/Rats/Others: Animals/Pets:
NOha
Others
36 Withsoap/Without
ablutioneating/After soap/Before washing: Hand
3t latrine/Open latrine/Public Househóld disposal: Excreta
Dinner cóllection/Others dumping/House bins/Open Covered disposal: Refuse
Drains/Septic
tank: covered items
Clean/Food Utensils:
Evening Biogas/LPG/Kerosene/Others room/Outdoor
Fuel: Separate/Living Kitchen:
H3t3 /PuifierBoiling/Straining/
Filter Purification:
\0 Intermittent Conthuous/ supply: Nature
of
Lunch \anK water: Storage
of toreo water: Source
of
Present/Absent Overcrowding: rooms:
| persons
per ofNo
1353b13 55 Brunch Inadequate Adeqúate/ Ventilation:
Adeqúate/Inadequate
CrossInadequate
Lighting: sheets Asbestos /ReC) /TiledThatched
Adequate/ Ventilation:
Roofing:
Protein Calorie Brdck/Mud/Thatti Walls: dung cow Tiled/Cemented/
and Mud Flooring:
quantity with items Food Breakfast Number feet) (Sq. OArea:
Timings rooms: of
mianddnight between previ
Rented/0Wn' Kutcha/PuCca/Semi-pucca Type:
day ous the eaten midnight. Housing
hia diet: Staple on drink and foood Record
all
method) recall dietaryiosd Mixed: Veg/ diet- of Type ENVIRONMENT
hour HISTORY:
(24 DIETARY
 87
86

Maeurne DIAGNOSIS: PROVISIONAL g0urd breh )NorralAuscultation:

aido Sg Percussion:
examination: system Other clso Palpation:,
midlno in \atha
is Inspection:
System
Respiratory
EXAMINATION SYSTEMIC

WHR:
circumference: Hip circumference: Waist
examination: Breast BMI:2 kg
Weight:
68 cm 55
Height:
Anthropometry
AdomiothoTacie Go
hygiene:Tongue/0ral
rate/type:
5 Respiratory Ho140 Pressure: Blood
radial/femoral/popliteal/dorsalispedis/posteriortibial) (carotid/brachial/
Examination: Local ft pulse
peripheral all equally
in Felt
rOd Radio-femoral
Nodelay
hictTirg vessl
o (atherosclerosis)
No thick wall Vessel
ortro Movemaroo ag8Dlin volume rhythm, rate, Pulse-
Bignianr Anle Temperature:
examination:
No Skin
Norra palpation: Thyroid Goon No
JVP:
joints: knee Examination
both of edema/Lymphadenopathy/Koilonychia:
si No Pallor/lcterus/Cyanosis/Clubbing
/Pedal
Ononaà person:
o and place time,Orientation
to
orgrdnagy siocooperative:
buit Built/Nourishment:
Msy
conscious
and Calm,
tord. Sognon aounishad
condition general Patient's
Abdomen: Examination
of EXAMINATION GENERAL

(fasting?):
o Customs
examination: System Nervous Central Nohe taboos:
beliefs/Food Food
week: Frequency
per outside:
NO eating Habit
of
hadi
no \32 Auscultation: intake:No foods Fried
oetion tormad in s peoePercussion:
Palpation: Most
ghee/Margarine
/Other: or Vegetble
oil/Butter oil: commonly
used
examination system Inspection:
Cardiovascular
 88

family: chart
ofPedigree
generation/
Joint Nuclear/Three family: the Type
of

practices: self-care Advice

on

3horth in follo
LKG
examínation: Follow
up

MamieDoha 33|M Fs 3. AsA

Moma tavostadin ci, cloidgrd
63|M Arotha
Thoorg1HlM 2
Treatment:

family
status Income Occupation Education status the of Mutitorrin
Sua
Health Marital Head Age/sex
to Name SN
Relation
MANAGENENT
PLAN cOMPREHENSIVE
members) family more (Expandif DETAILS FAMILY
Xoon a is He Sur
m \·5 km: Distance
in Maiotion obdie ensie
oitoitou
e facility: health Nearest
iSI
number: Contact DIAGNCEI
CLINICO-SOCIAL FINAL
honi Address:
Caste: Hirdn Religion:
Income:
Go horgoyd occupation: Eeno Advised:
Education
1Age: Traropuni Name:
Mle Gender:
hanrogam rdone: Already
CASE HEALTHGERIATRIC INVESTIGATIONS LAB
CASESTUDYCLINICO-SOCIAL INTEGRATED
 91
0

advised? was Whatmanifest? itdid Hownoticed? WhoNature?

complications
\o History
of
drugs: counter non-prescribed/
the over medicine
st sdon
in whi
ish ein h
or systems
of other ofuse H/o

notFollowing
? or detail.
progression
in and onset Describe
consultation? seek him madesymptom Which
Addictions:effect/Diet/Follow-up
Nona visits/ consumption/Adverse Drugeducation- Health
\akn dog 2 CoN status:
Vaccination Relevant
Chemoprophylaxis:
member: family Screeningof

Referral: ohoulde ha oh Xadictad

o ushioh
rer Sec T0boch

follow-up/investigations:
ra Frequency
of
days. baore2 rorml panarnty
consultations:\ Numberof illness:presenting H/o

drugs: effects
of Side

ESpiih doylst-A hqarin. \M-

Name/Dosage/Frequency/Duration:

received: treatmenttreatment/Typeof ona qor ain Ch

Placesof
HISTORYTREATMENT COMPLAINTS CHIEF
 93
Finances Managing
D
Driving 92

Medications
--OS---OO
D A ToiletTaki
ing ng
D A Housework
D Eating
D MealPreparing
s
D Bathing
Shopping
D Dressing
D
Telephone Using
D
D
A Walking
A
tasks?
following the each
of with all) at(cannot
do dependent
(D) person),
or another
from help (need assistance
(A) require myself), bydo
independent
(can () you Are
Living: Daily Activities
of
services:
So Satisfaction
with
Sregs Stress:
o
Type:No
Personality /work: wage ofLoss
allergy/reaction:
No drug History
of
GmHygiene: Non care: Extra
Normal habits: bladder and Bowel
Tgoad Nutrition:
ml,frequency: drink: peramount average yes, If No
Travel:
No
Yes/spirits? wior
ne, beer, drink,alcoholic
Consuming/Consumedan
frequency: item: mention yes, If homoduno huton e qBrpardo
or Treatment:

betel]:tobacco, chewing (snuff, products

Yes/No, pchet hia fiom SpardoInvestigation:
tobaccosmokeless any usingCurrently
frequency: yes, If
item: mention fee:raConsultation
:Yes/No cigarettes,
bidi such
as
products, tobacco smoking
any Currently visit each For
HISTORY PERSONAL DISEASE IMPACT
OF

Moderate Mil/d Mi/ld Very None/

thcdicti d is he Severe Very Severe/ during / had you have pain
bodily much How
weeks? past4 the
Go Good/ Go0d/ Very Excellent/ In
Poor Fai/r
health
is: your you would general,
say TH: HEAL GENERAL
HISTORY PAST
 95 94

recálled watch)# dog, (pen, minute after1 recall item 3test:Memory 9.

Ramila}e a HTN/DM:
tend screened
for members Family NoYe/s years? past5 the vaccine
in received
any you Have 8.
goteren family:complications
in morbidities/ of
List No /Yes you? harm intentionally
tried
to anyone Has 7.
Nó Yeactive?
/s sexually you Are 6.
erslon DM/HTN/CHD/CVA/Kidney
diseases: H/o Family
None chart/ orList help/ Family Pilbox/
consarquraous consanguinity:
Non History
of medications? your taking system
for your is
What
HISTORY FAMILY vitamins? cOunter
and
the prescribed,
over including day, per take you medicines
do many How 5.
Pre-eclampsia/Eclampsia: History
of wishes? Communicate
your
Soh
G/P/A:
toable not were youdecisions
if care health withyou help wOuld Who
HISTORYOBSTETRICS
birth/Contraception:
280hS Child emergency? an in
you help would Who
MOried
Status/Duration: Relative/ Other/ Child/ Spouse/ yes, If
Friend
HISTORY MARITAL anyone? with live you Do 4.
NoYes/
week? per drinkS many how yes, If
bleeding:
Postmenopausal menopause: attainment
of ofAge
cycles: irregular Regular
or alcohol? drink you Do h.
menarche: atAge Nó) Yes/
HISTORY MENSTRUAL Nong year? past the inhad you have falls many How g.
bowels? yOur control of withtrouble have you Do
No Yes/
your controlof with trouble have you Do f.
Total NÑ Yes/ bladder?
you Have e.
day
Nd Yes/ months? 6 the weight
last inunintentionally
lost
typical aon yOu Do d.
depressed? orsad feel often
spent Time NO Yes/ C.
days/week memory? your with problems have you Do
Number
of No Yes/
aids? hearing use you Do
work] continuously No Yes/ hear you Can b.
cycling] cycling) or construction conversational
voice? normal
[walking, (walking loads] digging, No Yes/
activities lightcarrying 10
least at No Ye/s
places walking, (brisk loads,
[heavy activities
for poor because
of reading or
fitness from
Travel
to
intensity
a intensity intensity these of
eyesight?
have you Do a.
Sports, Moderate Vigorous involves
any watching
TV driving, difficulty
Recreational Mild
Systems: of Geriatric
Review
Travel activity related Work Work
your Does
ACTIVITY PHYSICAL
 97
96
Ghrn /Services: Color card: Ration
Savings/Debts:
No
job:
towards Attitude
care/Recreations/Education: Diet7Medical Expenditure
on: Unemployment:
duration: andreason
income:
o family Total
hazards: exposure
to ofH/o previous: andCurrent
conditions Economic
HISTORY
OCCUPATIONAL
Stigma:
he ro bov illness: present towards Attitude
DISEASE TOWARDS ATTITUDE
Mosquito/Rats/Others:
yD
NO Pets:
Animals// area.)
ablútioneating/After soap/Before soap/Without Witwashing:
h Hand the elderly
in the schemes
for services
and the about know expected
to student
is (The
latrine/Open Public latrineHousehold
/ disposal: Excreta elderly?
NO schemes
for service social availing
any you Are
collection/Others dumping/House bìns/Open Covered disposal: any aware you Are
Refuse elderly?
No schemes
for service SOcial of
Rxmrd Drains/Septic
tank: age/interest
s inyou simliar
tO are who people grOup
of any part
of yoU Are
functions
3 religious community, family, including functions social attend you Do
covered items Food Cleán/ Utensils: Sactive socially you Are
LPG/Kerosene/Others Biogas/ Fuel:
room/Outdoor Sepárate/Living Kitchen: illness?
y during you of takemembers
care family Do
PurifierBoiling/Straining/
Filte/r Purification: TDoperdt
dependent/independent Economically
Cotínuous/Intermittent supply: Nature
of others?
No fromlanguage abusive face you Do
Torte water: Storage
of neglected?
No lonely
or feel often you Do
Source
te/Inadequate Ventilation:
AbsentPresent/
Overcrowding: Cros rdqrrd
bore
rooms:
2
water:
persons
per
of
of No
others?
NO with adjust difficult
to
Interpersonal
itfind you Do
the members relationship
Inadequate Adequáte/ Lighting: Inadequate Adeuate/ Ventilation: family
No of other with
HISTORY SOCIAL
Bick/Mud/Thatti Wal s: RCC/Asbestos Thatched/Tiled/
sheets Roofing: SUgoriQ relationship: Intra-familial disease
on impact
of
rooms:3 TMed7Cemented/Mud
dung cow and Flooring: Sonhospital/getting
drugs: accompanies
to who
of
Number Vyg illness: towards family Response of
Rented/Own \20 feet) (Sq. Area: sn 0i9e support: Emotional
PuetalSemi-pucca Kutcha/ Type: family:No Stress
on
Housing relationships Famly
ENVIRONMENT
 99
98

Others

cu)togom
(arro)
) Rie
Dinner

31 15Yca
(fasting?):
No Customs Evening

Nohg taboos:
beliefs/Food Food week: per
2rorhs onoorayFrequency
inOra outside: eating of
Habit
Lunch
No
intake: foods Fried
ghee/Margarine
/Other: oil/Butter
or Vegetable oil: cemmonly
used Most
Salt/Pickles/Papad/Chutney/Salty
No foods: processed Brunch

Breakfast
Total Timings
vegetables eat you
Protein Calorie
quantity with items Food
days many
do how week, typical
on aIn
midnight. and
2 fruit? eat you days many
do week, typical aIn
Amount
how on
midnight between previous
day the eaten
on drink and food Record
all
Servin/g Days diet: Staple
consumption vegetable and Eruits
recall dietary hour HISTORY:
(24 DIETARY
Veg/Mixed: diet- ofmethod)
Type
pension: age Old
security: social frombenefits Other
ossjet Yoal 832 intake Protein Gas/Cythder/Stove/Kerosene: NoPDS:through Food
schemes Welfare
Deficit/Excess intake Calorie
intake Actual Recommended conditions:
NO economic todue strain Family
hesrd cardAadhaar
 101
I00

examination: Breast

Abdomen: Examination
of
circumference:
WHR: Yalm BMIHi: p
820
circumference: Waist
Weight:S2kg cm158 Height:
Anthropometry
examination: System Nervous Central
Norm hygiene:Tongue/Oral
dsingd borso Coudioe Percussion: 1\min rate/type: Respiratory 12180
n Pressure: Blood
radial/femoral/popliteal/dorsalispedis/
posteriortibial) (carotid/brachial/
ostt noYma in se tofourd iqune Palpation:
ic pulse
peripheral all equally
in Felt
Radio-femoral
delay
(atherosclerosis) thick wall Vessel
\min volume rhythm,
68 rate, Pulse-
examination System
Cardiovascular
Temperature:
Auscultation:
Tormo examination:
on
Skin
NoJVP:
PercusS1on: palpation: Thyroid
edema/Lymphadenopathy/ Pallor/lcterus/Cyanosis/Clubbing
/Pedal
Palpation:7 Koilonychia:
Abgsr time,Orientation
to
0ir person: and place
oRoi nscioD
O cooperative: conscious
and Calm,
\ohoo Inspection: Mday
bul Built/Nourishment:
condition general Patient's
SystemRespiratory EXAMINATION GENERAL
first) system (relevantEXAMINATION cySTEMIC
 103
102

Advised:

Innoigio done:
B Already

INVESTIGATIONS LAB

practices: care self Advice

on

examination: Follow
up

DIAGNOSIS: PROVISIONAL

Treatment:

rat
ution ugearaial examination Local

MANAGEMENT
PLAN cOMPREHENSIVE

aoraig
fron trole araadnai,h
ad DIAGNOSICLIS NICO-SOCIAL
examination: system Other
CNAL
 105
104
wD oirt services: Satisfaction
with
qubrk abasu todue tOSS Eromla)
QOL/Stress/Tension/Pain
Guilt: of
Loss breth. 8rotnRS .
oK abgera
in omoYoy work: wage/ of
Loss
care: Extra
Woduogiviipothn
to
jcan cororcg Treatment: Travel:
illness:presenting H/o
RET LÌ root codiac investigation:EcG
EOo COMPLAINTS CHIEF
fre Consultation
fee:
visit each For
DISEASE IMPACT
OF

non-prescribed
drugs: medicineor systems
inorochs. olog
tha
of other
gof
not?Followinor
use H/o
family: chart
ofPedigree
generation/Joint Nuelear/Three family: the Type
of
rositatit
LFTeRFT investigations/PSlehysical Diet/Follow-upactivity/Addictions
education- uoalth
ac ECHo, Eo fol ow-gsgolup/ouoinvestigatioNo
ns: raquna Referral:
o
Erequencyof
potisr by got eRds consultations:
Si0 Number
of ryh18M
drugs:
No effectofs cide 3yA nTTama 80h
stort trgHositd-
io chothie/Dosage/Frequency/Duration:
to Ngotovl
redetceiailvsed/Trdreugsatment treatment
AD25000 lauur stgth Mamed
HoF to
status Name SN
treatment/Type
of status Education Marital Relation Age/sex
Places
of Health Income Occupation FAMILY
HISTORYTREATMENT members) family more (Expandif DETAILS
reDistance facility:inoy
hattth health Nearest
SOm. km: in Bnwtptthu Address:
number: Contact Hind Religion:
poçn Occupation
ran)Income: Caste: CReiid imuntg
vi
8C00 Gender:
std :gth Education Guurrdhon Name:
progres ion AD $5Age:
consultation?
and onsetDescribe
detail. in
NON-COMMUNICABLE
CASE DISEASE
se k him STUDYCLINICO-SOCIAL
CASE INTEGRATED
madesymptom Which
 107 106

duration:
NO Unemployment:
and reason bleeding:
Postmenopausal
God previous: andCurrent menopause: attainment
of of
Age cycles: irregular Regular
or
hazards:
No exposure
to of
H/o
cycle: each Duration
of menarche: atAge
HISTORY
OCCUPATIONAL HISTORY MENSTRUAL
48hro
irm tomh Stigma:
No
ilness: present towards Attitude
30minto 8hhel
Total
day
reOV ull he onidgrt i He typical aon
DISEASE TOWARDS ATTITUDE spend Time
days/week
relationship:
NO Inter-familial disease
on Impactof Number
of
INoemerN rous groups: socialInvolvement
in work] continuously
ieipÝion. festivals/marriages/social
hdiue activities: Participationin Construction
min
cycling) cycling] or loads] digging,
G\m person: towards society Response
of [walking. (walking lightcarrying loads, activities
for
10
least at
places walking, [brisk [heavy
activities these of
Gm
society: Interaction
with fitness from intensity
& intensity intensity involves
any
Societal/Neighborhood
Goorelations: Moderate Vigorous
Sports, Travel
to Mild work
activity related Work your Does
HISTORY SOCIAL Recreational Travel
ACTIVITY PHYSICAL
shess Ono Stress:
relationship:O Intra-familial disease
on Impact
of Com Type:
Personality
Oe his oons drugs:/getting hospital accompanies
to who allergy drug History
of
Coovoxdive illness: towards family Response
of dg
\ /reaction:
No Hygiene:
e qor falouirg
TsR
support:
Gs Emotional
rabts Traci hgenie
family: Stress
on oVSTaris habits:Padead
ou bladder and Bowel
relationships Family badd tton
in Aypat Sap Sleep/appetite:
Nomo
amount average yes, If
NO
HTN/DM: sScreened
for members Family frequency: duration: ml, drink: per
Consuming
morbidities/complications
family:
o in of
List alcoholic an
Yes/No spirits? or beer, drink,
wine,
DM/HTN/CHD/CVA/Kidney mention yes, Yes/No,
Yf
diseases:
NO H/oFamily frequency: duration:
smokeless any Currently
using
consorquns chewing [snuff,products tobacco
consanguinity:
Non- Hiof
story betell: tobacco,
frequency: duration: mention yes, If
smoking
any Currently
HISTORY FAMILY cigarettes, products, tobacco
such
as
Yes/Nó' bidi? HISTORY PERSONAL
Preeclampsia/Eclampsia:. Histoof
ry
G/P/A: hidoy Sigrigiaant
ut No
HISTORYOBSTETRICS
rth/Contraception:12 Child 2-yODu oStatus/Duration:
Mani HISTORY PAST

HISTORY MARITAL