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

•

• X'!S: "'-'$.- (""~ ~ .. ,~ ;::)fDa) ~'\J. Gf'K25- P

-eo~c ~cs~ ~.,...,Ol ~-~r:;e~

• os6t a~<S t;Sb~ r:~~~~ .... .:... ~ e~. X~ 10-12 §dec~~. n~ ~6l &tt ~oru ~fJ~ r.e Q~ ~11!1)X~;rj~.

• x~tl) ~e e...~~.~. aoa11s GS>ea5» ;5o 6~ ~ 6.6. ooii!Jl:S b~§"~~.

oo &e.l 6. 6. ~oa:~&_~ b~s'.SM>. ,., .lc'S

~iS~

• -~('I.-;"'"" ~""'.o(..;.:::"'tr~·' ~e'- ·D. r'>t:!:>6' ~1'(~,~·6· "'1~~0 &~~ ...... () ,..Ql<tr-t~.r ~j, s-<·r~ --~~-- &~at..

" ~ ;:5~ ... ($) ~~~;:6- ~~c1 ~~-'

<V'"e.Drl>.;r~ ~df\: ~()~(» &mo~r; .,..(),

~e~ :O:b~o ~" f>.ll .• cs~ ~aS» tu,..~i ~15~ ... " t~err la»o6ls';Jit{) .

• &'.)~ GS>edSD e'llli ~~ ~t!S o'et>e c..!i6 ~.,ytS ~C::.St3;:6,.

./ ~~iS KO~i:JOOCXI

• 7:6 ~~ t;S~~§ ~.,..~ -~ex_&:;> ru§~

~i1~ ~iSe~ ~iS c::NS~

~~iS ~o;:S6 fl-~ ~e» (~ rr'CS~}

~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

. ' ~

3

4

il~ ~cs~~ I ~~oS~ I e:cS~ g)oS~~eX) (History of Past Pregnancy)

J

~~~~~= ------------------------------------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:

I

! '" !

I I -I

I I

"-> -> I I

i I I

I

I

I

I

I

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 !

I

6. !&6~~~J

7. 6~l?'iSifu> I (~~)

s. e;srstm r I

r 1

~-------------------------- 4 ·--------------------------~

S).~. ~o.:

1~ efet> 3~ r~~ 7tl r~~ 2tl w-6o 3tl w-~o 4c6 OJD6o 6~ OJ'I6o 1. ~~e~ n

~rbtb~d.e/&>tJ

2. &a~efl~t:l . (~:l§ ~~~)

s.~~§ffo~

4. 23S6~

5. e~ btm/~e:&e

6. lfil'~eD

7. sa~~

8.~¥~8~~

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

~ ~~·~a

""fi",P

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 ----------------~

~ ~ot;, o~~Q:) ~~:,ol>CSSi ~o~~ ~~tS, I cSfbr.S 6'~ 'ilol?'~A b~s~D • «>~ ~o'h t1l>~w ~K~~~~c:So • £>~~ !.J~sr.r:oc , ~!lo b~g'oStrcoA ~~~o ~'~~o. • uo~~w, uo~<b ~~~ dof\)6' ~odG£o • ~~~o~ iS~~""~oG£~o • ~6cSo ~Ei»~G£o ~~~ ~G~tS 1 fJff ~e\S~U) &P~~~~ . Et ~-a~~w f90l)r6~~. • 6 ~~~~~ :,vv~ 6l>e:7w ~~, :S~cb ~~!>. p M U M ~

• 6 ~vw c-~i\l ~~~~ ~~w ~~boS~ Q~() . • f...u5 . .)5 ~;So I Xoes I ~;S e~.sl>. • ;s.,..~w ti~~NJ. u~~oc;r ~;S~Fio-LJWl>. ~~so • ::,~v~ b~~.sdo oS"3 tS~:O ~o2! ~a- eJ~ir iSJGSJes~;s ~ruw, S'~~;s fSS~;rol),

lit;S ~~es ~ ;;;o~e • ~Xo~ ~::,o &o.iJGo~CJ, ~:,o b~c!So gti~fS~(i) ~c'O i~~iSJ ucS'X~ sof':OA b~~~~l>.

• 23W~. ~c56o -&oc:S~o

,~ Ktt~o ~~:DeS ~ot,~ ~G ~ ~'\) ~~.;~~ I 6oK:5~e c5~ e:sf15 ~Ql)o~ID ,~ <!9~0Sl!' ~CS~o ~~!_eSo :c.z- ~~rS ;5o~-;8 ll~S:> ~~~e» ~~ID. ~vuoe t:SCS ~ooo;el) O)~ov6.:>. '~ 6 ~eJe> ~~ U~e>O 6~~e.:o ~~~ t:>~£> ~~ f;JO~~ofi ~co i$~~ ~rS~f\oi:jQ£> ~~ .;>~CSJ>~ ec53.Jv~~ e~CS:> OSJo~~ ~cov 1:$' lD~ru ti~o ~c;s.)t1Joco ED~ tSsoeJ ~e ;o~~~ ~~eD Ql):,..)o~D

Elo ~C)Q t.J~ toCSJ~ ~o~:SOJl'e go~oe ~co£> SV~eJdS.Jo es~ ~oc~

;)~.~ •• (SHG)

-~ ~ . .;):5.;)o.

~IS4e~~5

~. :,.~.~s. ~.

!?ii§ e~IS5 (G:).~.~ • .J~.)

I!Q! ~~ W~QS"O

I'

@J~~l!" iJ~: "' ~tSJ~~ . . es~ ~o. . ($~0llP ~~ .

.I

~~----------------------12 ----------------------~

.Q ,.. '

'{

Q i1 ~~3 g ) -a

'IJ ..,. ) ,gr

~6 ~ ~ Q,. a ~ ® r. . a m 'fl:) \,; ~ ~ cC

~ YJ '"'d ~ g 0 ~ )C

,./"< .jl P-.G lfh ': ~n y -BE 'fT2 : ,. .f.. a .a~-~ fi6

gt: ,3 ~ ~ . t() ~ 4 l- Q

'12 Q) • QJ :3 fl'2 -8 Q)[

Q '.~ ~ ..Q e'Cl .fl'Z CD I =

• ·•

6 1r ·.;;f Q b . . B. io f! Q !ltl 0 ~ino <O

fa '0 0 '12 m n ..,?,a a 6 m crr2 'fO .3 I: ~ 'fY'2 0 ~, r: 6:> • rra e ~'£) aQ'fe

ar ~~ fa ~r ~ § ~ ~ ; ~ r n'Cl ~ Q _.,_: )'C) ! ' {. ~

I,..., ~ l ·' y: ':1 . I'C. , -1 _1 'I) l · ':

4 ( ' - ,.

~ , 'l: yJ ~ OE ,...c c.t.: 'fo ~ rQ o'a I c,o • • •

8 '1e ' bd ( ~ (

,. 0 ): --~ 5;J Q <;, ~ JO !J3 ~

'0 6 rla . g .;g} "4' pa Q 0 'fO ,J 0 -liJ fJ 0 ~

~ QooaP-.!l ~'C) ~[ Q'C) Q fd ~ Q '12 "'() Q ~ '.8 '0 Q) en ,.... 6!1 'J

fn ~ ~ ~ ~- ~ < Q I") p_ 4'l " ' ~ J ('\ e..

'So J::. Cf)_ ~ .. ·~ (1'~- ~ I,S ID '0 UQJ .J,.; Q- . - •· o

6 0 ·r.. K g o'il .. C: -8 c5a [ ~ 'in fl, ) . r Y' 0 'fT2 ~ tt:a\ r ) ~' C ~ 0 nC VQI , ,, 1l 'J ~ c.u ,fa Q, ~d f! , err, .:.

- Q YJ )~ ID LO '!(. -:-) \ - QJ • '12 '12 . .a 0 « v~ 1g 0 tn "'J m ~ Yl ; . ' 1C. _!l , . t IQ.I ~ "'a~ 'f:• -

'I(. '(, )' '; :.I In iU 'fl:) "! ; .; C\1 YJ [' , · )() 1> ~ r '!. II _ .• • • ......

. Q fJ 0

Gl'Cl Q . @ Q

~[ {l 0 'fiJ

')'() 0

~'B Ai )Pa (N )?.

0 tJ ai ~

6 'fa. :~:= r '.8£ o

fa tfi ~ Q ro 1{2 -- an 6

'?. ru Q( lO 'fo .eta II • • eN

~ . ~

~ i! ~ -~;,

'!./

~ ~

~ ~

~ ~

~ ~